Robert Finn

SAN FRANCISCO — The near future of nuclear cardiology will be a bright one, with several important developments expected within the next 3 years, Manuel D. Cerqueira, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

New technology and improvements to current technology will lead to more information and greater efficiencies, reported Dr. Cerqueira of the Cleveland Clinic.

Dr. Cerqueira highlighted a number of advances:

▸ Attenuation from the breast and diaphragm and scatter from the liver and gut are big problems, especially in women and obese patients. Scanners with combined single-proton emission computed tomography (SPECT) and CT are beginning to address these issues.

A combined, six-slice, SPECT/CT provides high-quality SPECT images with attenuation, scatter, and resolution correction. It also provides calcium scoring and CT coronary angiography.

But these scanners are expensive, they're quite large, and they require shielding, he said.

“We had to basically take two imaging rooms and combine them to put this system in place,” Dr. Cerqueira said.

He added that new, smaller systems tailored to the practice setting will soon become available.

▸ PET scanners and combined PET/CT scanners will also make important contributions to cardiology. PET has much higher spatial resolution than SPECT, about 4–5 mm, vs. 16 mm. Attenuation correction can be quite accurate with these systems, and they can be used to make precise measurements of absolute myocardial blood flow and coronary flow reserve. This is especially important in the context of balanced disease, which is otherwise difficult to diagnose.

▸ Single acquisition rest/stress testing using two isotopes may soon become a reality.

Dr. Cerqueira envisions a protocol involving an initial infusion of 4.5 mCi of thallium-201, followed 30 minutes later by a stress test.

At the conclusion of the stress test would be an infusion of 9.0 mCi of technetium-99m, followed 30 minutes later by the acquisition of a rest image.

▸ Just a stress study, with no accompanying rest study, could be used to improve efficiency in certain patients.

The best candidates would be patients judged to be of low risk on the basis of risk factors, calcium scoring, or biomarkers. If the stress study proved to be normal, they would not need a rest study, according to Dr. Cerqueira.

On the other hand, if the stress study results proved to be abnormal, management decisions could be made on the basis of that study alone, or a rest study could be ordered.

▸ New systems to image vulnerable plaques may soon become a reality. Several constituents of vulnerable plaques provide inviting targets for radiotracers, he commented.

These include LDL cholesterol, oxidized LDL cholesterol, HDL cholesterol, membrane components of macrophages such as metalloproteinases, G-protein signaling or tyrosine kinase from smooth muscle cells, and clotting components, Dr. Cerqueira said.

SAN FRANCISCO — The near future of nuclear cardiology will be a bright one, with several important developments expected within the next 3 years, Manuel D. Cerqueira, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

New technology and improvements to current technology will lead to more information and greater efficiencies, reported Dr. Cerqueira of the Cleveland Clinic.

Dr. Cerqueira highlighted a number of advances:

▸ Attenuation from the breast and diaphragm and scatter from the liver and gut are big problems, especially in women and obese patients. Scanners with combined single-proton emission computed tomography (SPECT) and CT are beginning to address these issues.

A combined, six-slice, SPECT/CT provides high-quality SPECT images with attenuation, scatter, and resolution correction. It also provides calcium scoring and CT coronary angiography.

But these scanners are expensive, they're quite large, and they require shielding, he said.

“We had to basically take two imaging rooms and combine them to put this system in place,” Dr. Cerqueira said.

He added that new, smaller systems tailored to the practice setting will soon become available.

▸ PET scanners and combined PET/CT scanners will also make important contributions to cardiology. PET has much higher spatial resolution than SPECT, about 4–5 mm, vs. 16 mm. Attenuation correction can be quite accurate with these systems, and they can be used to make precise measurements of absolute myocardial blood flow and coronary flow reserve. This is especially important in the context of balanced disease, which is otherwise difficult to diagnose.

▸ Single acquisition rest/stress testing using two isotopes may soon become a reality.

Dr. Cerqueira envisions a protocol involving an initial infusion of 4.5 mCi of thallium-201, followed 30 minutes later by a stress test.

At the conclusion of the stress test would be an infusion of 9.0 mCi of technetium-99m, followed 30 minutes later by the acquisition of a rest image.

▸ Just a stress study, with no accompanying rest study, could be used to improve efficiency in certain patients.

The best candidates would be patients judged to be of low risk on the basis of risk factors, calcium scoring, or biomarkers. If the stress study proved to be normal, they would not need a rest study, according to Dr. Cerqueira.

On the other hand, if the stress study results proved to be abnormal, management decisions could be made on the basis of that study alone, or a rest study could be ordered.

▸ New systems to image vulnerable plaques may soon become a reality. Several constituents of vulnerable plaques provide inviting targets for radiotracers, he commented.

These include LDL cholesterol, oxidized LDL cholesterol, HDL cholesterol, membrane components of macrophages such as metalloproteinases, G-protein signaling or tyrosine kinase from smooth muscle cells, and clotting components, Dr. Cerqueira said.

SAN FRANCISCO — The near future of nuclear cardiology will be a bright one, with several important developments expected within the next 3 years, Manuel D. Cerqueira, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

New technology and improvements to current technology will lead to more information and greater efficiencies, reported Dr. Cerqueira of the Cleveland Clinic.

Dr. Cerqueira highlighted a number of advances:

▸ Attenuation from the breast and diaphragm and scatter from the liver and gut are big problems, especially in women and obese patients. Scanners with combined single-proton emission computed tomography (SPECT) and CT are beginning to address these issues.

A combined, six-slice, SPECT/CT provides high-quality SPECT images with attenuation, scatter, and resolution correction. It also provides calcium scoring and CT coronary angiography.

But these scanners are expensive, they're quite large, and they require shielding, he said.

“We had to basically take two imaging rooms and combine them to put this system in place,” Dr. Cerqueira said.

He added that new, smaller systems tailored to the practice setting will soon become available.

▸ PET scanners and combined PET/CT scanners will also make important contributions to cardiology. PET has much higher spatial resolution than SPECT, about 4–5 mm, vs. 16 mm. Attenuation correction can be quite accurate with these systems, and they can be used to make precise measurements of absolute myocardial blood flow and coronary flow reserve. This is especially important in the context of balanced disease, which is otherwise difficult to diagnose.

▸ Single acquisition rest/stress testing using two isotopes may soon become a reality.

Dr. Cerqueira envisions a protocol involving an initial infusion of 4.5 mCi of thallium-201, followed 30 minutes later by a stress test.

At the conclusion of the stress test would be an infusion of 9.0 mCi of technetium-99m, followed 30 minutes later by the acquisition of a rest image.

▸ Just a stress study, with no accompanying rest study, could be used to improve efficiency in certain patients.

The best candidates would be patients judged to be of low risk on the basis of risk factors, calcium scoring, or biomarkers. If the stress study proved to be normal, they would not need a rest study, according to Dr. Cerqueira.

On the other hand, if the stress study results proved to be abnormal, management decisions could be made on the basis of that study alone, or a rest study could be ordered.

▸ New systems to image vulnerable plaques may soon become a reality. Several constituents of vulnerable plaques provide inviting targets for radiotracers, he commented.

These include LDL cholesterol, oxidized LDL cholesterol, HDL cholesterol, membrane components of macrophages such as metalloproteinases, G-protein signaling or tyrosine kinase from smooth muscle cells, and clotting components, Dr. Cerqueira said.

SAN FRANCISCO — Cardiac magnetic resonance with late gadolinium enhancement is the imaging technique of choice when the goal is tissue characterization and infarct detection in heart failure, Christopher M. Kramer, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

While echocardiography—especially 3-D echocardiography—has its advantages, CMR provides outstanding image quality, excellent quantification, and tissue characterization, said Dr. Kramer of the University of Virginia, in Charlottesville.

Gadolinium contrast is easy to use and safe with CMR. The technique also offers the ability to assess intramural function. But CMR devices are not portable, are quite expensive, and are not readily available. Physicians need extensive training in the use of CMR and the technique is suitable for patients with implanted metallic devices such as pacemakers and implantable cardioverter defibrillators. Furthermore, assessment of diastolic function is not routine with CMR.

Echocardiography does have a number of advantages. The devices are portable, relatively inexpensive, and readily available. Generations of cardiologists have established its validity and all cardiologists become proficient in the use of echo during their training. Contrast can be added to echocardiography, and the assessment of diastolic function has become routine.

But echocardiography is subject to variable image quality and poor windows. Results tend to be qualitative, and quantitation can be difficult. Newer 3-D echocardiographic techniques address some of these issues, but these devices are not widely available.

Gadolinium-enhanced CMR has proved to be especially useful in determining whether cardiomyopathy is ischemic or nonischemic. In one study of 90 patients (63 with dilated cardiomyopathy and 27 with coronary artery disease) and 15 controls, none of the controls showed any hyperenhancement. All the patients with coronary artery disease showed hyperenhancement. And among the patients with dilated cardiomyopathy, 59% had no hyperenhancement, 13% had hyperenhancement consistent with coronary artery disease, and 28% had mid-wall hyperenhancement (Circulation 2003;108:54–9).

Enhanced CMR is also useful as a marker of late-stage myocarditis. In a study of 32 patients with myocarditis, investigators noted enhancement in 28 (88%) of them, with the lateral free wall the most common site. Twenty-one of the patients had biopsy in the area of enhancement, and active myocarditis was detected in 19. Of the other 11 patients, only 1 had active disease (Circulation 2004;109:1250–8).

Other studies have shown the value of enhanced CMR in hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, and Chagas disease.

Dr. Kramer concluded that echocardiography is fine in several circumstances, especially for diastolic function and when “quick and easy” is adequate. CMR, on the other hand, is best for regional systolic function, for differential diagnosis and tissue characterization, and whenever quantitation is needed and 3-D echo is unavailable.

SAN FRANCISCO — Cardiac magnetic resonance with late gadolinium enhancement is the imaging technique of choice when the goal is tissue characterization and infarct detection in heart failure, Christopher M. Kramer, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

While echocardiography—especially 3-D echocardiography—has its advantages, CMR provides outstanding image quality, excellent quantification, and tissue characterization, said Dr. Kramer of the University of Virginia, in Charlottesville.

Gadolinium contrast is easy to use and safe with CMR. The technique also offers the ability to assess intramural function. But CMR devices are not portable, are quite expensive, and are not readily available. Physicians need extensive training in the use of CMR and the technique is suitable for patients with implanted metallic devices such as pacemakers and implantable cardioverter defibrillators. Furthermore, assessment of diastolic function is not routine with CMR.

Echocardiography does have a number of advantages. The devices are portable, relatively inexpensive, and readily available. Generations of cardiologists have established its validity and all cardiologists become proficient in the use of echo during their training. Contrast can be added to echocardiography, and the assessment of diastolic function has become routine.

But echocardiography is subject to variable image quality and poor windows. Results tend to be qualitative, and quantitation can be difficult. Newer 3-D echocardiographic techniques address some of these issues, but these devices are not widely available.

Gadolinium-enhanced CMR has proved to be especially useful in determining whether cardiomyopathy is ischemic or nonischemic. In one study of 90 patients (63 with dilated cardiomyopathy and 27 with coronary artery disease) and 15 controls, none of the controls showed any hyperenhancement. All the patients with coronary artery disease showed hyperenhancement. And among the patients with dilated cardiomyopathy, 59% had no hyperenhancement, 13% had hyperenhancement consistent with coronary artery disease, and 28% had mid-wall hyperenhancement (Circulation 2003;108:54–9).

Enhanced CMR is also useful as a marker of late-stage myocarditis. In a study of 32 patients with myocarditis, investigators noted enhancement in 28 (88%) of them, with the lateral free wall the most common site. Twenty-one of the patients had biopsy in the area of enhancement, and active myocarditis was detected in 19. Of the other 11 patients, only 1 had active disease (Circulation 2004;109:1250–8).

Other studies have shown the value of enhanced CMR in hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, and Chagas disease.

Dr. Kramer concluded that echocardiography is fine in several circumstances, especially for diastolic function and when “quick and easy” is adequate. CMR, on the other hand, is best for regional systolic function, for differential diagnosis and tissue characterization, and whenever quantitation is needed and 3-D echo is unavailable.

SAN FRANCISCO — Cardiac magnetic resonance with late gadolinium enhancement is the imaging technique of choice when the goal is tissue characterization and infarct detection in heart failure, Christopher M. Kramer, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

While echocardiography—especially 3-D echocardiography—has its advantages, CMR provides outstanding image quality, excellent quantification, and tissue characterization, said Dr. Kramer of the University of Virginia, in Charlottesville.

Gadolinium contrast is easy to use and safe with CMR. The technique also offers the ability to assess intramural function. But CMR devices are not portable, are quite expensive, and are not readily available. Physicians need extensive training in the use of CMR and the technique is suitable for patients with implanted metallic devices such as pacemakers and implantable cardioverter defibrillators. Furthermore, assessment of diastolic function is not routine with CMR.

Echocardiography does have a number of advantages. The devices are portable, relatively inexpensive, and readily available. Generations of cardiologists have established its validity and all cardiologists become proficient in the use of echo during their training. Contrast can be added to echocardiography, and the assessment of diastolic function has become routine.

But echocardiography is subject to variable image quality and poor windows. Results tend to be qualitative, and quantitation can be difficult. Newer 3-D echocardiographic techniques address some of these issues, but these devices are not widely available.

Gadolinium-enhanced CMR has proved to be especially useful in determining whether cardiomyopathy is ischemic or nonischemic. In one study of 90 patients (63 with dilated cardiomyopathy and 27 with coronary artery disease) and 15 controls, none of the controls showed any hyperenhancement. All the patients with coronary artery disease showed hyperenhancement. And among the patients with dilated cardiomyopathy, 59% had no hyperenhancement, 13% had hyperenhancement consistent with coronary artery disease, and 28% had mid-wall hyperenhancement (Circulation 2003;108:54–9).

Enhanced CMR is also useful as a marker of late-stage myocarditis. In a study of 32 patients with myocarditis, investigators noted enhancement in 28 (88%) of them, with the lateral free wall the most common site. Twenty-one of the patients had biopsy in the area of enhancement, and active myocarditis was detected in 19. Of the other 11 patients, only 1 had active disease (Circulation 2004;109:1250–8).

Other studies have shown the value of enhanced CMR in hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, and Chagas disease.

Dr. Kramer concluded that echocardiography is fine in several circumstances, especially for diastolic function and when “quick and easy” is adequate. CMR, on the other hand, is best for regional systolic function, for differential diagnosis and tissue characterization, and whenever quantitation is needed and 3-D echo is unavailable.

SAN FRANCISCO — Studies show that about 70% of patients with heart failure also have coronary artery disease, and the decision about whether to intervene surgically or medically is a complex one, Patrick T. O'Gara, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Imaging can assist in making the decision, said Dr. O'Gara of Harvard Medical School (Boston). “Imaging should provide detection of the disease that we suspect and should characterize it further,” he said. “It should also provide us with an assessment of long-term prognosis and the risks that our patients face for adverse events in the intermediate term. It should then clarify the way for the treatment options that are available to us, [and] we should rely on imaging to assess the response to therapy when it is otherwise not clear to us from a clinical perspective.”

Cardiac imaging is useful only to the extent that it provides information not readily available by more conventional means, such as a history, a physical exam, an ECG, or a chest x-ray.

Of the data that cardiac imaging can provide, assessments of left ventricular size and systolic function are the most important. This information allows the clinician to separate patients whose heart failure arises from systolic function from patients whose heart failure arises from valvular, pericardial, or intramyocardial causes.

The issue of viability is particularly salient, Dr. O'Gara said. A metaanalysis of studies involving 3,088 patients with comorbid heart failure and coronary artery disease indicated that patients with viable but hibernating myocardium have a significantly lower mortality rate after revascularization than do patients with nonviable myocardium (J. Am. Coll. Cardiol. 2002;39:1151–8).

On the other hand, patients with viable myocardium appear to have a much higher mortality rate with medical therapy than do those with nonviable myocardium.

This metaanalysis has come under a good deal of criticism, Dr. O'Gara acknowledged. Some of the included studies were observational, nonrandomized, and unblinded. They had varying patient-selection criteria, varying methodologies, and varying definitions of viability. Nevertheless, he said, the message that emerges is that the demonstration of viability seems to be important.

Most clinicians would say that patients need to have viability in at least 25%–30% of the myocardial mass to be good candidates for revascularization, but this has never been evaluated prospectively.

Other studies have shown that the survival advantages of coronary artery bypass grafting (CABG) are greatest for those patients with the most extensive coronary disease, the greatest degree of left ventricular systolic dysfunction, and the greatest degree of ischemia.

The 2001 heart failure guidelines from the American College of Cardiology and the American Heart Association say that either angiography or noninvasive assessments of ischemia and viability is appropriate for a patient with both coronary disease and left ventricular systolic dysfunction, usually defined by a left ventricular ejection fraction of 35% or less.

The 2005 guidelines, released within days of Dr. O'Gara's talk, say that coronary angiography should be performed on heart failure patients with angina or ischemia unless they are not candidates for revascularization of any kind (class I recommendation). Coronary angiography is reasonable for patients with chest pain that may or may not be of cardiac origin or those who have known or suspected coronary artery disease without angina, unless the patient is not eligible for revascularization of any kind (class IIa recommendation).

Separate CABG guidelines from the same organizations state that there is good evidence that left main stenosis or two- or three-vessel disease in the left anterior descending artery are indications for CABG. There is somewhat less evidence in favor of CABG for “significantly viable noncontracting revascularizable myocardium.” The problem is that the term “significantly viable” is not defined precisely.

“The heart failure panel looked at it differently, and they warned us that coronary revascularization of patients who have heart failure and coronary disease but do not have a history of angina has never been demonstrated to be useful,” Dr. O'Gara said. This statement is unchanged in the 2005 guidelines.

In practice, most clinicians would consider it mandatory to search for coronary artery disease in patients with heart failure and a left ventricular ejection fraction of less than 40%. Either angiography or noninvasive assessment of ischemia and viability would be appropriate.

“Some would prefer coronary angiography to settle the issue as to whether or not appropriate targets are available for revascularization, if the patient is shown to have demonstrable ischemia,” he said. “You need to have the targets and you need to have the conduits before you can move ahead with revascularization.”

Beyond that, the clinician must ask a series of questions to determine whether the patient is a good candidate for revascularization. Among the considerations are the patient's general health status, whether he or she will have adequate support at home during the recovery period, whether the patient has a history of angina, and the experience level of the surgeon and the hospital.

“These are not the kind of patients who should be operated on by low-volume operators in low-volume institutions,” he said.

He offered no strong recommendations on which specific imaging tests would be best, except to say that in practice clinicians should rely on the modality that has the greatest degree of reproducibility and accuracy in the local community.

Finally, he recommended counseling the patient and the family on the basis of widely available risk calculators.

SAN FRANCISCO — Studies show that about 70% of patients with heart failure also have coronary artery disease, and the decision about whether to intervene surgically or medically is a complex one, Patrick T. O'Gara, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Imaging can assist in making the decision, said Dr. O'Gara of Harvard Medical School (Boston). “Imaging should provide detection of the disease that we suspect and should characterize it further,” he said. “It should also provide us with an assessment of long-term prognosis and the risks that our patients face for adverse events in the intermediate term. It should then clarify the way for the treatment options that are available to us, [and] we should rely on imaging to assess the response to therapy when it is otherwise not clear to us from a clinical perspective.”

Cardiac imaging is useful only to the extent that it provides information not readily available by more conventional means, such as a history, a physical exam, an ECG, or a chest x-ray.

Of the data that cardiac imaging can provide, assessments of left ventricular size and systolic function are the most important. This information allows the clinician to separate patients whose heart failure arises from systolic function from patients whose heart failure arises from valvular, pericardial, or intramyocardial causes.

The issue of viability is particularly salient, Dr. O'Gara said. A metaanalysis of studies involving 3,088 patients with comorbid heart failure and coronary artery disease indicated that patients with viable but hibernating myocardium have a significantly lower mortality rate after revascularization than do patients with nonviable myocardium (J. Am. Coll. Cardiol. 2002;39:1151–8).

On the other hand, patients with viable myocardium appear to have a much higher mortality rate with medical therapy than do those with nonviable myocardium.

This metaanalysis has come under a good deal of criticism, Dr. O'Gara acknowledged. Some of the included studies were observational, nonrandomized, and unblinded. They had varying patient-selection criteria, varying methodologies, and varying definitions of viability. Nevertheless, he said, the message that emerges is that the demonstration of viability seems to be important.

Most clinicians would say that patients need to have viability in at least 25%–30% of the myocardial mass to be good candidates for revascularization, but this has never been evaluated prospectively.

Other studies have shown that the survival advantages of coronary artery bypass grafting (CABG) are greatest for those patients with the most extensive coronary disease, the greatest degree of left ventricular systolic dysfunction, and the greatest degree of ischemia.

The 2001 heart failure guidelines from the American College of Cardiology and the American Heart Association say that either angiography or noninvasive assessments of ischemia and viability is appropriate for a patient with both coronary disease and left ventricular systolic dysfunction, usually defined by a left ventricular ejection fraction of 35% or less.

The 2005 guidelines, released within days of Dr. O'Gara's talk, say that coronary angiography should be performed on heart failure patients with angina or ischemia unless they are not candidates for revascularization of any kind (class I recommendation). Coronary angiography is reasonable for patients with chest pain that may or may not be of cardiac origin or those who have known or suspected coronary artery disease without angina, unless the patient is not eligible for revascularization of any kind (class IIa recommendation).

Separate CABG guidelines from the same organizations state that there is good evidence that left main stenosis or two- or three-vessel disease in the left anterior descending artery are indications for CABG. There is somewhat less evidence in favor of CABG for “significantly viable noncontracting revascularizable myocardium.” The problem is that the term “significantly viable” is not defined precisely.

“The heart failure panel looked at it differently, and they warned us that coronary revascularization of patients who have heart failure and coronary disease but do not have a history of angina has never been demonstrated to be useful,” Dr. O'Gara said. This statement is unchanged in the 2005 guidelines.

In practice, most clinicians would consider it mandatory to search for coronary artery disease in patients with heart failure and a left ventricular ejection fraction of less than 40%. Either angiography or noninvasive assessment of ischemia and viability would be appropriate.

“Some would prefer coronary angiography to settle the issue as to whether or not appropriate targets are available for revascularization, if the patient is shown to have demonstrable ischemia,” he said. “You need to have the targets and you need to have the conduits before you can move ahead with revascularization.”

Beyond that, the clinician must ask a series of questions to determine whether the patient is a good candidate for revascularization. Among the considerations are the patient's general health status, whether he or she will have adequate support at home during the recovery period, whether the patient has a history of angina, and the experience level of the surgeon and the hospital.

“These are not the kind of patients who should be operated on by low-volume operators in low-volume institutions,” he said.

He offered no strong recommendations on which specific imaging tests would be best, except to say that in practice clinicians should rely on the modality that has the greatest degree of reproducibility and accuracy in the local community.

Finally, he recommended counseling the patient and the family on the basis of widely available risk calculators.

SAN FRANCISCO — Studies show that about 70% of patients with heart failure also have coronary artery disease, and the decision about whether to intervene surgically or medically is a complex one, Patrick T. O'Gara, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Imaging can assist in making the decision, said Dr. O'Gara of Harvard Medical School (Boston). “Imaging should provide detection of the disease that we suspect and should characterize it further,” he said. “It should also provide us with an assessment of long-term prognosis and the risks that our patients face for adverse events in the intermediate term. It should then clarify the way for the treatment options that are available to us, [and] we should rely on imaging to assess the response to therapy when it is otherwise not clear to us from a clinical perspective.”

Cardiac imaging is useful only to the extent that it provides information not readily available by more conventional means, such as a history, a physical exam, an ECG, or a chest x-ray.

Of the data that cardiac imaging can provide, assessments of left ventricular size and systolic function are the most important. This information allows the clinician to separate patients whose heart failure arises from systolic function from patients whose heart failure arises from valvular, pericardial, or intramyocardial causes.

The issue of viability is particularly salient, Dr. O'Gara said. A metaanalysis of studies involving 3,088 patients with comorbid heart failure and coronary artery disease indicated that patients with viable but hibernating myocardium have a significantly lower mortality rate after revascularization than do patients with nonviable myocardium (J. Am. Coll. Cardiol. 2002;39:1151–8).

On the other hand, patients with viable myocardium appear to have a much higher mortality rate with medical therapy than do those with nonviable myocardium.

This metaanalysis has come under a good deal of criticism, Dr. O'Gara acknowledged. Some of the included studies were observational, nonrandomized, and unblinded. They had varying patient-selection criteria, varying methodologies, and varying definitions of viability. Nevertheless, he said, the message that emerges is that the demonstration of viability seems to be important.

Most clinicians would say that patients need to have viability in at least 25%–30% of the myocardial mass to be good candidates for revascularization, but this has never been evaluated prospectively.

Other studies have shown that the survival advantages of coronary artery bypass grafting (CABG) are greatest for those patients with the most extensive coronary disease, the greatest degree of left ventricular systolic dysfunction, and the greatest degree of ischemia.

The 2001 heart failure guidelines from the American College of Cardiology and the American Heart Association say that either angiography or noninvasive assessments of ischemia and viability is appropriate for a patient with both coronary disease and left ventricular systolic dysfunction, usually defined by a left ventricular ejection fraction of 35% or less.

The 2005 guidelines, released within days of Dr. O'Gara's talk, say that coronary angiography should be performed on heart failure patients with angina or ischemia unless they are not candidates for revascularization of any kind (class I recommendation). Coronary angiography is reasonable for patients with chest pain that may or may not be of cardiac origin or those who have known or suspected coronary artery disease without angina, unless the patient is not eligible for revascularization of any kind (class IIa recommendation).

Separate CABG guidelines from the same organizations state that there is good evidence that left main stenosis or two- or three-vessel disease in the left anterior descending artery are indications for CABG. There is somewhat less evidence in favor of CABG for “significantly viable noncontracting revascularizable myocardium.” The problem is that the term “significantly viable” is not defined precisely.

“The heart failure panel looked at it differently, and they warned us that coronary revascularization of patients who have heart failure and coronary disease but do not have a history of angina has never been demonstrated to be useful,” Dr. O'Gara said. This statement is unchanged in the 2005 guidelines.

In practice, most clinicians would consider it mandatory to search for coronary artery disease in patients with heart failure and a left ventricular ejection fraction of less than 40%. Either angiography or noninvasive assessment of ischemia and viability would be appropriate.

“Some would prefer coronary angiography to settle the issue as to whether or not appropriate targets are available for revascularization, if the patient is shown to have demonstrable ischemia,” he said. “You need to have the targets and you need to have the conduits before you can move ahead with revascularization.”

Beyond that, the clinician must ask a series of questions to determine whether the patient is a good candidate for revascularization. Among the considerations are the patient's general health status, whether he or she will have adequate support at home during the recovery period, whether the patient has a history of angina, and the experience level of the surgeon and the hospital.

“These are not the kind of patients who should be operated on by low-volume operators in low-volume institutions,” he said.

He offered no strong recommendations on which specific imaging tests would be best, except to say that in practice clinicians should rely on the modality that has the greatest degree of reproducibility and accuracy in the local community.

Finally, he recommended counseling the patient and the family on the basis of widely available risk calculators.

Almost two-thirds of people with four normal wisdom teeth show signs of periodontal disease in their 20s, and in many the periodontal disease is progressive, according to a study discussed at a press briefing sponsored by the American Association of Oral and Maxillofacial Surgeons.

“Most people would think that you don't get periodontal disease until you are 35 years old,” said Raymond P. White Jr., D.D.S., one of the authors of the study.

“The finding that surprised all of us is that the prevalence of periodontal disease in people in their 20s is much higher than anyone would have anticipated,” said Dr. White of the University of North Carolina at Chapel Hill.

He expected that only about 10% of people in this age group would have signs of periodontal disease.

Many other studies have confirmed linkages between periodontal disease and a number of systemic illnesses including coronary artery disease, stroke, renal vascular disease, diabetes, and obstetric complications.

As a result, Dr. White recommended that adults be evaluated for periodontal disease well before the age of 25, and if disease is present they should give serious thought to having their wisdom teeth removed, even if they're asymptomatic.

The study involved 254 individuals, mean age 27.5, who had four asymptomatic wisdom teeth (more formally known as “third molars”), and who were followed for at least 2 years; 93% of the subjects were at least high-school graduates.

At baseline, 59% of the subjects had a periodontal probing depth (PD) of 4 mm or more on at least one wisdom tooth, and 26% had a PD of 5 mm or more.

Gingival pockets of at least 3–4 mm in depth indicate the presence of periodontal disease.

Among the subjects who had PDs of 4 mm or more, 38% experienced an increase in PD of at least 2 mm in the subsequent 2 years.

More than half of those subjects had other indicators of periodontal disease, including high levels of bacteria and inflammatory markers. Subjects with both a baseline third molar PD of at least 4 mm and high bacteria levels had 19.7 times the chance of having progressive periodontal disease, compared with subjects with neither risk factor.

Removing the wisdom teeth is not the only option for patients with periodontal disease. Scaling and root planing every 3 or 4 months is another approach, but dentists have a difficult time working that far back in the mouth.

Studies have shown that dentists are unlikely to remove more than 50% of the bacteria in patients with deep gingival pockets, Dr. White noted.

The message to patients is, “If you ignore [this] and you don't do something about it, you're running the risk of chronic oral inflammation and then not only problems in your mouth but also systemic problems,” Dr. White said.

“Just because you have no symptoms doesn't mean that you have no problem. What we're recommending is that everybody with wisdom teeth should have them evaluated. Twenty percent or maybe 25% of people can keep their wisdom teeth with no problems, but you can't ignore them. They need to be evaluated seriously,” he added.

Almost two-thirds of people with four normal wisdom teeth show signs of periodontal disease in their 20s, and in many the periodontal disease is progressive, according to a study discussed at a press briefing sponsored by the American Association of Oral and Maxillofacial Surgeons.

“Most people would think that you don't get periodontal disease until you are 35 years old,” said Raymond P. White Jr., D.D.S., one of the authors of the study.

“The finding that surprised all of us is that the prevalence of periodontal disease in people in their 20s is much higher than anyone would have anticipated,” said Dr. White of the University of North Carolina at Chapel Hill.

He expected that only about 10% of people in this age group would have signs of periodontal disease.

Many other studies have confirmed linkages between periodontal disease and a number of systemic illnesses including coronary artery disease, stroke, renal vascular disease, diabetes, and obstetric complications.

As a result, Dr. White recommended that adults be evaluated for periodontal disease well before the age of 25, and if disease is present they should give serious thought to having their wisdom teeth removed, even if they're asymptomatic.

The study involved 254 individuals, mean age 27.5, who had four asymptomatic wisdom teeth (more formally known as “third molars”), and who were followed for at least 2 years; 93% of the subjects were at least high-school graduates.

At baseline, 59% of the subjects had a periodontal probing depth (PD) of 4 mm or more on at least one wisdom tooth, and 26% had a PD of 5 mm or more.

Gingival pockets of at least 3–4 mm in depth indicate the presence of periodontal disease.

Among the subjects who had PDs of 4 mm or more, 38% experienced an increase in PD of at least 2 mm in the subsequent 2 years.

More than half of those subjects had other indicators of periodontal disease, including high levels of bacteria and inflammatory markers. Subjects with both a baseline third molar PD of at least 4 mm and high bacteria levels had 19.7 times the chance of having progressive periodontal disease, compared with subjects with neither risk factor.

Removing the wisdom teeth is not the only option for patients with periodontal disease. Scaling and root planing every 3 or 4 months is another approach, but dentists have a difficult time working that far back in the mouth.

Studies have shown that dentists are unlikely to remove more than 50% of the bacteria in patients with deep gingival pockets, Dr. White noted.

The message to patients is, “If you ignore [this] and you don't do something about it, you're running the risk of chronic oral inflammation and then not only problems in your mouth but also systemic problems,” Dr. White said.

“Just because you have no symptoms doesn't mean that you have no problem. What we're recommending is that everybody with wisdom teeth should have them evaluated. Twenty percent or maybe 25% of people can keep their wisdom teeth with no problems, but you can't ignore them. They need to be evaluated seriously,” he added.

Almost two-thirds of people with four normal wisdom teeth show signs of periodontal disease in their 20s, and in many the periodontal disease is progressive, according to a study discussed at a press briefing sponsored by the American Association of Oral and Maxillofacial Surgeons.

“Most people would think that you don't get periodontal disease until you are 35 years old,” said Raymond P. White Jr., D.D.S., one of the authors of the study.

“The finding that surprised all of us is that the prevalence of periodontal disease in people in their 20s is much higher than anyone would have anticipated,” said Dr. White of the University of North Carolina at Chapel Hill.

He expected that only about 10% of people in this age group would have signs of periodontal disease.

Many other studies have confirmed linkages between periodontal disease and a number of systemic illnesses including coronary artery disease, stroke, renal vascular disease, diabetes, and obstetric complications.

As a result, Dr. White recommended that adults be evaluated for periodontal disease well before the age of 25, and if disease is present they should give serious thought to having their wisdom teeth removed, even if they're asymptomatic.

The study involved 254 individuals, mean age 27.5, who had four asymptomatic wisdom teeth (more formally known as “third molars”), and who were followed for at least 2 years; 93% of the subjects were at least high-school graduates.

At baseline, 59% of the subjects had a periodontal probing depth (PD) of 4 mm or more on at least one wisdom tooth, and 26% had a PD of 5 mm or more.

Gingival pockets of at least 3–4 mm in depth indicate the presence of periodontal disease.

Among the subjects who had PDs of 4 mm or more, 38% experienced an increase in PD of at least 2 mm in the subsequent 2 years.

More than half of those subjects had other indicators of periodontal disease, including high levels of bacteria and inflammatory markers. Subjects with both a baseline third molar PD of at least 4 mm and high bacteria levels had 19.7 times the chance of having progressive periodontal disease, compared with subjects with neither risk factor.

Removing the wisdom teeth is not the only option for patients with periodontal disease. Scaling and root planing every 3 or 4 months is another approach, but dentists have a difficult time working that far back in the mouth.

Studies have shown that dentists are unlikely to remove more than 50% of the bacteria in patients with deep gingival pockets, Dr. White noted.

The message to patients is, “If you ignore [this] and you don't do something about it, you're running the risk of chronic oral inflammation and then not only problems in your mouth but also systemic problems,” Dr. White said.

“Just because you have no symptoms doesn't mean that you have no problem. What we're recommending is that everybody with wisdom teeth should have them evaluated. Twenty percent or maybe 25% of people can keep their wisdom teeth with no problems, but you can't ignore them. They need to be evaluated seriously,” he added.

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in the emergency department, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Dr. Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs.

Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said.

“There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath.

Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents to the emergency department at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have a workstation with the proper software at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

On the left: an aortic dissection appears as a long, thin dissection flap in the descending aorta. In the center: an endoscopic view of the aortic dissection shows the true lumen (larger area) and false lumen. On the right: a high-grade stenosis is shown in the mid-left anterior descending artery. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in the emergency department, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Dr. Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs.

Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said.

“There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath.

Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents to the emergency department at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have a workstation with the proper software at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

On the left: an aortic dissection appears as a long, thin dissection flap in the descending aorta. In the center: an endoscopic view of the aortic dissection shows the true lumen (larger area) and false lumen. On the right: a high-grade stenosis is shown in the mid-left anterior descending artery. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Chest pain represents one of the most common presenting symptoms in the emergency department, and it also represents a diagnostic challenge: Is it a pulmonary embolism? Is it an aortic dissection? Is it coronary artery disease? Or is it nothing?

Now, new CT technology promises to revolutionize this diagnosis, giving the ability to rule out all three conditions with a single 15-second scan.

In theory, this scan can replace stress testing for coronary artery disease, echocardiography or CT for aortic dissection, and CT pulmonary angiography or a ventilation-perfusion scan for pulmonary embolism, Dr. Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Although no diagnostic or prognostic studies on the triple rule out have yet been published, there's some indication that the single scan will have 90% accuracy or better for each of the three conditions, said Dr. Budoff of Harbor-UCLA Medical Center in Torrance, Calif.

The technology involves a 64-slice CT scan from the apex to the base of the lungs.

Patients will have to hold their breath for 20–30 seconds as contrast is injected and the images are acquired. Acquisition of the slices will be gated to the heart's rhythm, allowing for stable, high-resolution images of the heart and lungs. The slice thickness will be 0.625 mm.

Software and a sophisticated workstation will allow the clinician to construct three-dimensional images of the heart, lungs, or aorta, and to manipulate three-dimensional and two-dimensional images in a variety of ways.

In addition to aortic dissection, pulmonary embolism, and coronary artery disease, the technique will allow clear views of the pericardium, permitting the diagnosis of calcified or thickened pericardium and sometimes pericarditis.

In addition, “you might pick up pneumonia, and you might pick up pulmonary adhesions or even pericardial adhesions,” Dr. Budoff said.

“There are a lot of things you could possibly see. And it could be done during the chest pain episode, which is a great advantage over some of the other modalities where you'd want to wait until their chest pain is quiescent.”

Dr. Budoff described the case of an elderly woman who complained of chest pain and shortness of breath.

Because of her age, he was reluctant to order a stress test. The CT angiography showed that her coronary arteries were normal and that her ejection fraction was acceptably high. When he examined the lung images closely, however, he discovered several pulmonary emboli.

“We admitted her to the hospital, put her on heparin, and it all cleared up,” he said.

Despite its promise, the triple rule out does have some limitations. For one thing, it subjects patients to a relatively high dose of radiation—in the neighborhood of 24–30 millisieverts, equivalent to 240–300 chest x-rays.

Because it's a gated study, more contrast must be used and the injection time is longer than for a standard CT. Some patients may have trouble holding their breath for 20–30 seconds.

Then there's the issue of who is going to read these images when a patient presents to the emergency department at 3 a.m. The radiologist staffing the emergency department may not be facile with cardiac CT angiography. Although the images could be transferred over data lines, the cardiologist is not likely to have a workstation with the proper software at home. In all likelihood, someone will have to come to the hospital to read the study.

Still, Dr. Budoff expects the triple rule out to become a routine test in the emergency department, a prospect he greets with mixed emotions.

“We really need to see how this is going to pan out, and work out the reading issues before we start applying this to everybody who comes in with a twinge in their chest or shortness of breath,” he said. “I'm a little leery … to say just because we can do it we should.”

On the left: an aortic dissection appears as a long, thin dissection flap in the descending aorta. In the center: an endoscopic view of the aortic dissection shows the true lumen (larger area) and false lumen. On the right: a high-grade stenosis is shown in the mid-left anterior descending artery. Photos courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Quantitative nuclear cardiology allows for highly sensitive, specific, and reproducible estimates of a patient's risk, and assists in the decision of who should be sent for revascularization, Daniel S. Berman, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

When quantitative techniques are used with single photon emission computed tomography (SPECT), the results are operator independent, said Dr. Berman of Cedars-Sinai Medical Center, Los Angeles. A quantitative SPECT assessment of myocardial perfusion and function reduces the reliance on expert observers, standardizes results from center to center, facilitates serial assessments, and ultimately improves patient outcomes.

The technology produces reliable assessments of many important parameters of cardiac function (see box below), and numerous studies have shown how these parameters relate to cardiac risk.

For example, pooled data from more than 17,000 patients show that those with a normal stress myocardial perfusion SPECT had only a 0.6% chance of suffering cardiac death or a nonfatal MI over a mean follow-up of 27 months. This low rate of cardiac events is impressive because these were patients with known or suspected coronary artery disease.

This study included patients who were under either exercise or pharmacologic stress. According to another study, a normal stress myocardial perfusion SPECT has less prognostic value if the patient fails to reach at least 70% of the predicted maximal heart rate (PMHR) during exercise. Among more than 5,000 patients, the cardiac event rate for patients who failed to reach 70% PMHR was more than three times that of those who reached 70%–100% PMHR. Patients who are unable to reach 70% PMHR during exercise need to undergo myocardial perfusion SPECT with pharmacologic stress, Dr. Berman said.

The presence of diabetes is another factor that modifies a patient's risk after myocardial perfusion SPECT. For any given summed stress score (SSS)—an estimate of the overall size and severity of a perfusion defect during stress—nondiabetics have the lowest level of risk, insulin-dependent diabetics have the highest level of risk, and non-insulin-dependent diabetics have an intermediate risk. SSS alone isn't enough, however. The summed difference score, which subtracts the summed rest score from the SSS, is a more reliable measure.

Better still is to normalize these scores based on the maximum possible score. This yields measures of percent myocardium perfused that are independent of the specific SPECT system employed. When applied to the summed difference score, the percent myocardium perfused is a measure of ischemia.

This measure of ischemia is important in deciding whether to refer patients to revascularization or to treat them with medical therapy. Studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy.

Measurements Possible With Quantitative Cardiac Perfusion SPECT

Percent hypoperfusion.

Percent reversibility.

Lung-to-heart ratio.

Transient ischemic dilatation.

Left ventricular mass.

Left ventricular ejection fraction.

End diastolic volume.

End systolic volume.

Wall motion.

Wall thickening.

Peak filling rate.

Source: Dr. Berman

SAN FRANCISCO — Quantitative nuclear cardiology allows for highly sensitive, specific, and reproducible estimates of a patient's risk, and assists in the decision of who should be sent for revascularization, Daniel S. Berman, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

When quantitative techniques are used with single photon emission computed tomography (SPECT), the results are operator independent, said Dr. Berman of Cedars-Sinai Medical Center, Los Angeles. A quantitative SPECT assessment of myocardial perfusion and function reduces the reliance on expert observers, standardizes results from center to center, facilitates serial assessments, and ultimately improves patient outcomes.

The technology produces reliable assessments of many important parameters of cardiac function (see box below), and numerous studies have shown how these parameters relate to cardiac risk.

For example, pooled data from more than 17,000 patients show that those with a normal stress myocardial perfusion SPECT had only a 0.6% chance of suffering cardiac death or a nonfatal MI over a mean follow-up of 27 months. This low rate of cardiac events is impressive because these were patients with known or suspected coronary artery disease.

This study included patients who were under either exercise or pharmacologic stress. According to another study, a normal stress myocardial perfusion SPECT has less prognostic value if the patient fails to reach at least 70% of the predicted maximal heart rate (PMHR) during exercise. Among more than 5,000 patients, the cardiac event rate for patients who failed to reach 70% PMHR was more than three times that of those who reached 70%–100% PMHR. Patients who are unable to reach 70% PMHR during exercise need to undergo myocardial perfusion SPECT with pharmacologic stress, Dr. Berman said.

The presence of diabetes is another factor that modifies a patient's risk after myocardial perfusion SPECT. For any given summed stress score (SSS)—an estimate of the overall size and severity of a perfusion defect during stress—nondiabetics have the lowest level of risk, insulin-dependent diabetics have the highest level of risk, and non-insulin-dependent diabetics have an intermediate risk. SSS alone isn't enough, however. The summed difference score, which subtracts the summed rest score from the SSS, is a more reliable measure.

Better still is to normalize these scores based on the maximum possible score. This yields measures of percent myocardium perfused that are independent of the specific SPECT system employed. When applied to the summed difference score, the percent myocardium perfused is a measure of ischemia.

This measure of ischemia is important in deciding whether to refer patients to revascularization or to treat them with medical therapy. Studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy.

Measurements Possible With Quantitative Cardiac Perfusion SPECT

Percent hypoperfusion.

Percent reversibility.

Lung-to-heart ratio.

Transient ischemic dilatation.

Left ventricular mass.

Left ventricular ejection fraction.

End diastolic volume.

End systolic volume.

Wall motion.

Wall thickening.

Peak filling rate.

Source: Dr. Berman

SAN FRANCISCO — Quantitative nuclear cardiology allows for highly sensitive, specific, and reproducible estimates of a patient's risk, and assists in the decision of who should be sent for revascularization, Daniel S. Berman, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

When quantitative techniques are used with single photon emission computed tomography (SPECT), the results are operator independent, said Dr. Berman of Cedars-Sinai Medical Center, Los Angeles. A quantitative SPECT assessment of myocardial perfusion and function reduces the reliance on expert observers, standardizes results from center to center, facilitates serial assessments, and ultimately improves patient outcomes.

The technology produces reliable assessments of many important parameters of cardiac function (see box below), and numerous studies have shown how these parameters relate to cardiac risk.

For example, pooled data from more than 17,000 patients show that those with a normal stress myocardial perfusion SPECT had only a 0.6% chance of suffering cardiac death or a nonfatal MI over a mean follow-up of 27 months. This low rate of cardiac events is impressive because these were patients with known or suspected coronary artery disease.

This study included patients who were under either exercise or pharmacologic stress. According to another study, a normal stress myocardial perfusion SPECT has less prognostic value if the patient fails to reach at least 70% of the predicted maximal heart rate (PMHR) during exercise. Among more than 5,000 patients, the cardiac event rate for patients who failed to reach 70% PMHR was more than three times that of those who reached 70%–100% PMHR. Patients who are unable to reach 70% PMHR during exercise need to undergo myocardial perfusion SPECT with pharmacologic stress, Dr. Berman said.

The presence of diabetes is another factor that modifies a patient's risk after myocardial perfusion SPECT. For any given summed stress score (SSS)—an estimate of the overall size and severity of a perfusion defect during stress—nondiabetics have the lowest level of risk, insulin-dependent diabetics have the highest level of risk, and non-insulin-dependent diabetics have an intermediate risk. SSS alone isn't enough, however. The summed difference score, which subtracts the summed rest score from the SSS, is a more reliable measure.

Better still is to normalize these scores based on the maximum possible score. This yields measures of percent myocardium perfused that are independent of the specific SPECT system employed. When applied to the summed difference score, the percent myocardium perfused is a measure of ischemia.

This measure of ischemia is important in deciding whether to refer patients to revascularization or to treat them with medical therapy. Studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy.

Measurements Possible With Quantitative Cardiac Perfusion SPECT

Percent hypoperfusion.

Percent reversibility.

Lung-to-heart ratio.

Transient ischemic dilatation.

Left ventricular mass.

Left ventricular ejection fraction.

End diastolic volume.

End systolic volume.

Wall motion.

Wall thickening.

Peak filling rate.

Source: Dr. Berman

SAN FRANCISCO — The near future of nuclear cardiology will be a bright one, with several important developments expected within the next 3 years, Manuel D. Cerqueira, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

New technology and improvements to current technology will lead to more information and greater efficiencies, said Dr. Cerqueira of the Cleveland Clinic.

He highlighted a number of advances:

▸ Attenuation from the breast and diaphragm and scatter from the liver and gut are big problems, especially in women and obese patients. Scanners with combined single-proton emission computed tomography (SPECT) and CT are beginning to address these issues.

A combined, six-slice, SPECT/CT provides high-quality SPECT images with attenuation, scatter, and resolution correction. It also provides calcium scoring and CT coronary angiography.

But these scanners are expensive, quite large, and require shielding. “We had to basically take two imaging rooms and combine them to put this system in place,” Dr. Cerqueira said, adding that new, smaller systems will soon become available.

▸ PET scanners and combined PET/CT scanners will also make important contributions to cardiology. PET has much higher spatial resolution than SPECT, about 4–5 mm, vs. 16 mm. Attenuation correction can be quite accurate with these systems, and they can be used to make precise measurements of absolute myocardial blood flow and coronary flow reserve. This is important in the context of balanced disease, which is otherwise difficult to diagnose.

▸ Single acquisition rest/stress testing using two isotopes may soon become a reality. Dr. Cerqueira envisions a protocol involving an initial infusion of 4.5 mCi of thallium-201, followed 30 minutes later by a stress test. At the conclusion of the stress test would be an infusion of 9.0 mCi of technetium-99m, followed 30 minutes later by the acquisition of a rest image.

▸ Just a stress study, with no accompanying rest study, could be used to improve efficiency in certain patients. The best candidates would be patients judged to be of low risk on the basis of risk factors, calcium scoring, or biomarkers. If the stress study is normal, they wouldn't need a rest study, but if the stress study is abnormal, management decisions could be made on the basis of that study alone, or a rest study could be ordered.

▸ New systems to image vulnerable plaques may soon become a reality. Several constituents of vulnerable plaques provide inviting targets for radiotracers. These include LDL cholesterol, oxidized LDL cholesterol, HDL cholesterol, membrane components of macrophages such as metalloproteinases, G-protein signaling or tyrosine kinase from smooth muscle cells, and clotting components.

SAN FRANCISCO — The near future of nuclear cardiology will be a bright one, with several important developments expected within the next 3 years, Manuel D. Cerqueira, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

New technology and improvements to current technology will lead to more information and greater efficiencies, said Dr. Cerqueira of the Cleveland Clinic.

He highlighted a number of advances:

▸ Attenuation from the breast and diaphragm and scatter from the liver and gut are big problems, especially in women and obese patients. Scanners with combined single-proton emission computed tomography (SPECT) and CT are beginning to address these issues.

A combined, six-slice, SPECT/CT provides high-quality SPECT images with attenuation, scatter, and resolution correction. It also provides calcium scoring and CT coronary angiography.

But these scanners are expensive, quite large, and require shielding. “We had to basically take two imaging rooms and combine them to put this system in place,” Dr. Cerqueira said, adding that new, smaller systems will soon become available.

▸ PET scanners and combined PET/CT scanners will also make important contributions to cardiology. PET has much higher spatial resolution than SPECT, about 4–5 mm, vs. 16 mm. Attenuation correction can be quite accurate with these systems, and they can be used to make precise measurements of absolute myocardial blood flow and coronary flow reserve. This is important in the context of balanced disease, which is otherwise difficult to diagnose.

▸ Single acquisition rest/stress testing using two isotopes may soon become a reality. Dr. Cerqueira envisions a protocol involving an initial infusion of 4.5 mCi of thallium-201, followed 30 minutes later by a stress test. At the conclusion of the stress test would be an infusion of 9.0 mCi of technetium-99m, followed 30 minutes later by the acquisition of a rest image.

▸ Just a stress study, with no accompanying rest study, could be used to improve efficiency in certain patients. The best candidates would be patients judged to be of low risk on the basis of risk factors, calcium scoring, or biomarkers. If the stress study is normal, they wouldn't need a rest study, but if the stress study is abnormal, management decisions could be made on the basis of that study alone, or a rest study could be ordered.

▸ New systems to image vulnerable plaques may soon become a reality. Several constituents of vulnerable plaques provide inviting targets for radiotracers. These include LDL cholesterol, oxidized LDL cholesterol, HDL cholesterol, membrane components of macrophages such as metalloproteinases, G-protein signaling or tyrosine kinase from smooth muscle cells, and clotting components.

SAN FRANCISCO — The near future of nuclear cardiology will be a bright one, with several important developments expected within the next 3 years, Manuel D. Cerqueira, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

New technology and improvements to current technology will lead to more information and greater efficiencies, said Dr. Cerqueira of the Cleveland Clinic.

He highlighted a number of advances:

▸ Attenuation from the breast and diaphragm and scatter from the liver and gut are big problems, especially in women and obese patients. Scanners with combined single-proton emission computed tomography (SPECT) and CT are beginning to address these issues.

A combined, six-slice, SPECT/CT provides high-quality SPECT images with attenuation, scatter, and resolution correction. It also provides calcium scoring and CT coronary angiography.

But these scanners are expensive, quite large, and require shielding. “We had to basically take two imaging rooms and combine them to put this system in place,” Dr. Cerqueira said, adding that new, smaller systems will soon become available.

▸ PET scanners and combined PET/CT scanners will also make important contributions to cardiology. PET has much higher spatial resolution than SPECT, about 4–5 mm, vs. 16 mm. Attenuation correction can be quite accurate with these systems, and they can be used to make precise measurements of absolute myocardial blood flow and coronary flow reserve. This is important in the context of balanced disease, which is otherwise difficult to diagnose.

▸ Single acquisition rest/stress testing using two isotopes may soon become a reality. Dr. Cerqueira envisions a protocol involving an initial infusion of 4.5 mCi of thallium-201, followed 30 minutes later by a stress test. At the conclusion of the stress test would be an infusion of 9.0 mCi of technetium-99m, followed 30 minutes later by the acquisition of a rest image.

▸ Just a stress study, with no accompanying rest study, could be used to improve efficiency in certain patients. The best candidates would be patients judged to be of low risk on the basis of risk factors, calcium scoring, or biomarkers. If the stress study is normal, they wouldn't need a rest study, but if the stress study is abnormal, management decisions could be made on the basis of that study alone, or a rest study could be ordered.

▸ New systems to image vulnerable plaques may soon become a reality. Several constituents of vulnerable plaques provide inviting targets for radiotracers. These include LDL cholesterol, oxidized LDL cholesterol, HDL cholesterol, membrane components of macrophages such as metalloproteinases, G-protein signaling or tyrosine kinase from smooth muscle cells, and clotting components.

SAN ANTONIO — Highly effective treatments for interstitial cystitis remain elusive, but new concepts are enlivening the field, Deborah R. Erickson, M.D., said at the annual meeting of the American Urological Association.

Some of the concepts build on old ones, while others are completely new. But all are off-label, and with two exceptions they have not been subjected to placebo-controlled trials, cautioned Dr. Erickson, of the University of Kentucky (Lexington).

Here is a rundown of some interstitial cystitis (IC) treatment concepts she presented at the meeting:

▸ Finding ways to restore the deficient bladder epithelium is an old approach; several drugs are being developed with this in mind, but none is yet available.

▸ Another old concept focuses on mast cells—either inhibiting mast cell activation or blocking mast cell mediators. Ketotifen, a mast cell stabilizer, has proved effective when used topically in the eye and may be developed for IC. Montelukast, a leukotriene receptor blocker, has been the subject of one open-label trial in IC. Among 10 patients with IC and detrusor mastocytosis who had at least 28 mast cells per square millimeter of muscle tissue, 3 months of treatment with montelukast was associated with significant improvements in nocturia, day voids, and pain scores (J. Urol. 2001;166:1734–7).

▸ Immunosuppression is another old concept that's getting a fresh look. Until now, immunosuppression has not been popular for treating IC because it's too risky to apply to all patients, it's unclear which patients would do best with this strategy, and it's unclear when treatment can be stopped.

Patients with evidence of inflammation or autoimmune involvement may do best on immunosuppression. Such patients include those with the ulcer type of IC, those with evidence of inflammation on bladder biopsy, and those with high levels of urine mediators such as interleukin-6. High levels of nitric oxide gas also suggest inflammation, but special equipment is needed to measure gas levels.

In several recent open-label trials of patients selected for at least one of these signs, prednisone, prednisolone, and low-dose cyclosporine all have shown evidence of efficacy.

“The current status of immunosuppression in 2005 is [that] it's a valid concept, it's not a standard treatment, and the best drugs and doses are not well defined,” Dr. Erickson said. “The best patients are the ones who have failed conventional treatment, are well-informed and compliant, and have some evidence for the autoimmune or inflammatory type of IC.”

Another concept is to focus on nerves.

▸ Some patients with IC may have neuropathic pain, and gabapentin and pregabalin, which are well-studied treatments for neuropathic pain, may help. Several small open-label trials of gabapentin in IC have seemed to demonstrate efficacy.

▸ Many physicians have put lidocaine into the bladders of IC patients, but often this doesn't help, possibly because the acidic form of lidocaine is ionized and doesn't penetrate the epithelium very well. Two different formulations of alkalinized lidocaine appear to reduce bladder pain, but one of those forms seems to cause urethral pain on voiding.

▸ Sacral nerve stimulation has been approved by the Food and Drug Administration for significant symptoms of urgency/frequency. Some IC patients have this symptom. Three short-term studies and three longer-term studies appear to demonstrate efficacy in some patients.

▸ Lumbar epidural injections, typically with bupivacaine, have shown promise in three small trials. The methods varied widely, as did the duration of the effect (ranging from 0 to 75 days), so Dr. Erickson said more research clearly is needed.

▸ The only two drugs that have performed well in randomized, placebo-controlled trials are cimetidine and amitriptyline. Their mechanisms of action are unclear, and as a result neither fits into one of Dr. Erickson's concept categories.

In one study of 36 patients, cimetidine 400 mg b.i.d. resulted in significant improvements in suprapubic pain, nocturia, and total symptom score. The drug may work through histamine₂ receptors on mast cells or on T cells, or through reduced stomach acid secretion, which may translate into less acid excreted in urine.

SAN ANTONIO — Highly effective treatments for interstitial cystitis remain elusive, but new concepts are enlivening the field, Deborah R. Erickson, M.D., said at the annual meeting of the American Urological Association.

Some of the concepts build on old ones, while others are completely new. But all are off-label, and with two exceptions they have not been subjected to placebo-controlled trials, cautioned Dr. Erickson, of the University of Kentucky (Lexington).

Here is a rundown of some interstitial cystitis (IC) treatment concepts she presented at the meeting:

▸ Finding ways to restore the deficient bladder epithelium is an old approach; several drugs are being developed with this in mind, but none is yet available.

▸ Another old concept focuses on mast cells—either inhibiting mast cell activation or blocking mast cell mediators. Ketotifen, a mast cell stabilizer, has proved effective when used topically in the eye and may be developed for IC. Montelukast, a leukotriene receptor blocker, has been the subject of one open-label trial in IC. Among 10 patients with IC and detrusor mastocytosis who had at least 28 mast cells per square millimeter of muscle tissue, 3 months of treatment with montelukast was associated with significant improvements in nocturia, day voids, and pain scores (J. Urol. 2001;166:1734–7).

▸ Immunosuppression is another old concept that's getting a fresh look. Until now, immunosuppression has not been popular for treating IC because it's too risky to apply to all patients, it's unclear which patients would do best with this strategy, and it's unclear when treatment can be stopped.

Patients with evidence of inflammation or autoimmune involvement may do best on immunosuppression. Such patients include those with the ulcer type of IC, those with evidence of inflammation on bladder biopsy, and those with high levels of urine mediators such as interleukin-6. High levels of nitric oxide gas also suggest inflammation, but special equipment is needed to measure gas levels.

In several recent open-label trials of patients selected for at least one of these signs, prednisone, prednisolone, and low-dose cyclosporine all have shown evidence of efficacy.

“The current status of immunosuppression in 2005 is [that] it's a valid concept, it's not a standard treatment, and the best drugs and doses are not well defined,” Dr. Erickson said. “The best patients are the ones who have failed conventional treatment, are well-informed and compliant, and have some evidence for the autoimmune or inflammatory type of IC.”

Another concept is to focus on nerves.

▸ Some patients with IC may have neuropathic pain, and gabapentin and pregabalin, which are well-studied treatments for neuropathic pain, may help. Several small open-label trials of gabapentin in IC have seemed to demonstrate efficacy.

▸ Many physicians have put lidocaine into the bladders of IC patients, but often this doesn't help, possibly because the acidic form of lidocaine is ionized and doesn't penetrate the epithelium very well. Two different formulations of alkalinized lidocaine appear to reduce bladder pain, but one of those forms seems to cause urethral pain on voiding.

▸ Sacral nerve stimulation has been approved by the Food and Drug Administration for significant symptoms of urgency/frequency. Some IC patients have this symptom. Three short-term studies and three longer-term studies appear to demonstrate efficacy in some patients.

▸ Lumbar epidural injections, typically with bupivacaine, have shown promise in three small trials. The methods varied widely, as did the duration of the effect (ranging from 0 to 75 days), so Dr. Erickson said more research clearly is needed.

▸ The only two drugs that have performed well in randomized, placebo-controlled trials are cimetidine and amitriptyline. Their mechanisms of action are unclear, and as a result neither fits into one of Dr. Erickson's concept categories.

In one study of 36 patients, cimetidine 400 mg b.i.d. resulted in significant improvements in suprapubic pain, nocturia, and total symptom score. The drug may work through histamine₂ receptors on mast cells or on T cells, or through reduced stomach acid secretion, which may translate into less acid excreted in urine.

SAN ANTONIO — Highly effective treatments for interstitial cystitis remain elusive, but new concepts are enlivening the field, Deborah R. Erickson, M.D., said at the annual meeting of the American Urological Association.

Some of the concepts build on old ones, while others are completely new. But all are off-label, and with two exceptions they have not been subjected to placebo-controlled trials, cautioned Dr. Erickson, of the University of Kentucky (Lexington).

Here is a rundown of some interstitial cystitis (IC) treatment concepts she presented at the meeting:

▸ Finding ways to restore the deficient bladder epithelium is an old approach; several drugs are being developed with this in mind, but none is yet available.

▸ Another old concept focuses on mast cells—either inhibiting mast cell activation or blocking mast cell mediators. Ketotifen, a mast cell stabilizer, has proved effective when used topically in the eye and may be developed for IC. Montelukast, a leukotriene receptor blocker, has been the subject of one open-label trial in IC. Among 10 patients with IC and detrusor mastocytosis who had at least 28 mast cells per square millimeter of muscle tissue, 3 months of treatment with montelukast was associated with significant improvements in nocturia, day voids, and pain scores (J. Urol. 2001;166:1734–7).

▸ Immunosuppression is another old concept that's getting a fresh look. Until now, immunosuppression has not been popular for treating IC because it's too risky to apply to all patients, it's unclear which patients would do best with this strategy, and it's unclear when treatment can be stopped.

Patients with evidence of inflammation or autoimmune involvement may do best on immunosuppression. Such patients include those with the ulcer type of IC, those with evidence of inflammation on bladder biopsy, and those with high levels of urine mediators such as interleukin-6. High levels of nitric oxide gas also suggest inflammation, but special equipment is needed to measure gas levels.

In several recent open-label trials of patients selected for at least one of these signs, prednisone, prednisolone, and low-dose cyclosporine all have shown evidence of efficacy.

“The current status of immunosuppression in 2005 is [that] it's a valid concept, it's not a standard treatment, and the best drugs and doses are not well defined,” Dr. Erickson said. “The best patients are the ones who have failed conventional treatment, are well-informed and compliant, and have some evidence for the autoimmune or inflammatory type of IC.”

Another concept is to focus on nerves.

▸ Some patients with IC may have neuropathic pain, and gabapentin and pregabalin, which are well-studied treatments for neuropathic pain, may help. Several small open-label trials of gabapentin in IC have seemed to demonstrate efficacy.

▸ Many physicians have put lidocaine into the bladders of IC patients, but often this doesn't help, possibly because the acidic form of lidocaine is ionized and doesn't penetrate the epithelium very well. Two different formulations of alkalinized lidocaine appear to reduce bladder pain, but one of those forms seems to cause urethral pain on voiding.

▸ Sacral nerve stimulation has been approved by the Food and Drug Administration for significant symptoms of urgency/frequency. Some IC patients have this symptom. Three short-term studies and three longer-term studies appear to demonstrate efficacy in some patients.

▸ Lumbar epidural injections, typically with bupivacaine, have shown promise in three small trials. The methods varied widely, as did the duration of the effect (ranging from 0 to 75 days), so Dr. Erickson said more research clearly is needed.

▸ The only two drugs that have performed well in randomized, placebo-controlled trials are cimetidine and amitriptyline. Their mechanisms of action are unclear, and as a result neither fits into one of Dr. Erickson's concept categories.

In one study of 36 patients, cimetidine 400 mg b.i.d. resulted in significant improvements in suprapubic pain, nocturia, and total symptom score. The drug may work through histamine₂ receptors on mast cells or on T cells, or through reduced stomach acid secretion, which may translate into less acid excreted in urine.

Individuals with systemic lupus erythmatosus who go on to develop nephritis are more than five times as likely to have antibodies to lipoprotein lipase in their blood serum, according to findings from an investigation led by Morris Reichlin, M.D.

This suggests that the pathogenesis of lupus nephritis may involve cell-surface antigens that activate the complement system and promote vascular damage in the kidney and other organs when they are engaged by antibodies.

Other antibodies have previously been shown to be associated with systemic lupus nephritis, wrote Dr. Reichlin of the University of Oklahoma, in Oklahoma City.

These antibodies include anti-double-stranded DNA (anti-dsDNA), anti-ribosomal P protein (anti-P), anti-Ro/SSA, antihistones, anti-C₁q, and antinucleosomes. This is the first study to demonstrate an association between lupus nephritis and anti-lipoprotein lipase (anti-LPL).

According to the study, anti-LPL shows strong relationship to this SLE complication than any single specificity (Clin. Immunol. 2005;117:12–4).

In addition, Dr. Reichlin found that SLE patients with anti-LPL and anti-P antibodies were more than 17 times more likely to develop lupus nephritis than were those who had neither antibody. This result was highly significant, with a P value of .00002.

The study involved 35 patients with SLE who had developed nephritis that apparently had no other cause and 28 patients with SLE who had no evidence of nephritis.

Twenty-five (71.4%) of the patients with nephritis had anti-LPL antibodies in their serum compared with 9 (32%) of the patients without nephritis.

Twenty (57.1%) of the patients with nephritis had both anti-LPL and anti-P, compared with just two (7.1%) of the patients who as yet have no clinical evidence of nephritis.

“It will be of interest to follow those two patients to assess their outcomes,” Dr. Reichlin wrote.

Individuals with systemic lupus erythmatosus who go on to develop nephritis are more than five times as likely to have antibodies to lipoprotein lipase in their blood serum, according to findings from an investigation led by Morris Reichlin, M.D.

This suggests that the pathogenesis of lupus nephritis may involve cell-surface antigens that activate the complement system and promote vascular damage in the kidney and other organs when they are engaged by antibodies.

Other antibodies have previously been shown to be associated with systemic lupus nephritis, wrote Dr. Reichlin of the University of Oklahoma, in Oklahoma City.

These antibodies include anti-double-stranded DNA (anti-dsDNA), anti-ribosomal P protein (anti-P), anti-Ro/SSA, antihistones, anti-C₁q, and antinucleosomes. This is the first study to demonstrate an association between lupus nephritis and anti-lipoprotein lipase (anti-LPL).

According to the study, anti-LPL shows strong relationship to this SLE complication than any single specificity (Clin. Immunol. 2005;117:12–4).

In addition, Dr. Reichlin found that SLE patients with anti-LPL and anti-P antibodies were more than 17 times more likely to develop lupus nephritis than were those who had neither antibody. This result was highly significant, with a P value of .00002.

The study involved 35 patients with SLE who had developed nephritis that apparently had no other cause and 28 patients with SLE who had no evidence of nephritis.

Twenty-five (71.4%) of the patients with nephritis had anti-LPL antibodies in their serum compared with 9 (32%) of the patients without nephritis.

Twenty (57.1%) of the patients with nephritis had both anti-LPL and anti-P, compared with just two (7.1%) of the patients who as yet have no clinical evidence of nephritis.

“It will be of interest to follow those two patients to assess their outcomes,” Dr. Reichlin wrote.

Individuals with systemic lupus erythmatosus who go on to develop nephritis are more than five times as likely to have antibodies to lipoprotein lipase in their blood serum, according to findings from an investigation led by Morris Reichlin, M.D.

This suggests that the pathogenesis of lupus nephritis may involve cell-surface antigens that activate the complement system and promote vascular damage in the kidney and other organs when they are engaged by antibodies.

Other antibodies have previously been shown to be associated with systemic lupus nephritis, wrote Dr. Reichlin of the University of Oklahoma, in Oklahoma City.

These antibodies include anti-double-stranded DNA (anti-dsDNA), anti-ribosomal P protein (anti-P), anti-Ro/SSA, antihistones, anti-C₁q, and antinucleosomes. This is the first study to demonstrate an association between lupus nephritis and anti-lipoprotein lipase (anti-LPL).

According to the study, anti-LPL shows strong relationship to this SLE complication than any single specificity (Clin. Immunol. 2005;117:12–4).

In addition, Dr. Reichlin found that SLE patients with anti-LPL and anti-P antibodies were more than 17 times more likely to develop lupus nephritis than were those who had neither antibody. This result was highly significant, with a P value of .00002.

The study involved 35 patients with SLE who had developed nephritis that apparently had no other cause and 28 patients with SLE who had no evidence of nephritis.

Twenty-five (71.4%) of the patients with nephritis had anti-LPL antibodies in their serum compared with 9 (32%) of the patients without nephritis.

Twenty (57.1%) of the patients with nephritis had both anti-LPL and anti-P, compared with just two (7.1%) of the patients who as yet have no clinical evidence of nephritis.

“It will be of interest to follow those two patients to assess their outcomes,” Dr. Reichlin wrote.

SANTA BARBARA, CALIF. — While it's well known that bone mineral density testing should be routine for women over the age of 65, it can be difficult to decide whether to test other patients and difficult to know what to do with the results, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

The International Society for Clinical Densitometry and the National Osteoporosis Foundation list similar indications for testing bone mineral density (BMD), said Dr. Lukert of the University of Kansas Medical Center, Kansas City. While these guidelines appear straightforward, there are complexities.

The guidelines say that in addition to all women over 65, postmenopausal women under 65 with risk factors should be tested. But studies have not succeeded in identifying all of those risk factors, so in Dr. Lukert's view it's probably prudent to measure BMD in all postmenopausal women.

Premenopausal women, on the other hand, should not have their BMD measured routinely.

The guidelines also call for BMD testing in men over 70. “We know very little about the development of osteoporosis in men, except that we do know that it's much more common than we had previously thought,” Dr. Lukert said. “We aren't measuring bone density in men frequently enough.”

Similarly, the guidelines call for BMD testing in any adult who has had a fragility fracture, but in practice this is done only about 15% of the time, an oversight that Dr. Lukert described as “appalling.”

BMD testing should also be done in adults with any disease or condition associated with bone loss or low bone mass. The conditions include Cushing's disease, hyperthyroidism, hyperparathyroidism, and rheumatoid arthritis.

Some medications are associated with bone loss, most notably the glucocorticoids, and the guidelines say that any adult taking one of these medications should have BMD testing.

Any adult who's being considered for pharmacologic therapy for bone loss should have his or her BMD assessed, and anyone receiving that therapy should have BMD testing to monitor the treatment effect.

One complexity comes in interpreting the BMD results in some of these groups. For postmenopausal women one typically uses the T score, which compares the individual's BMD to a healthy young adult's. The T score is expressed in terms of the number of standard deviations the individual's BMD falls above or below this norm. The World Health Organization defines osteoporosis as a T score of -2.5 or below, and osteopenia as a T score between −1 and −2.5.

But in premenopausal women, men aged 50–64 with no risk factors, and in men aged 20–50 with risk factors, the use of T scores can be misleading. Instead, one should use the z score, which compares an individual's BMD with that of an age-matched sample. The use of T scores would imply a relationship with fracture risk that may not exist or may differ from group to group. A postmenopausal woman with a certain BMD would have many times the fracture risk of a premenopausal woman with the same BMD.

Once one has a T score or z score, the question becomes whether to treat the patient's osteoporosis or osteopenia. The National Osteoporosis Foundation recommends treating all women with a T score of -2 or below, and women with at least one additional risk factor and a T score of −1.5 or below.

On the other hand, a recent study determined that it was not cost effective to treat osteopenic women because treatment does not significantly reduce their fracture risk over a 5-year period (Ann. Intern. Med. 2005;142:734–41).

But Dr. Lukert pointed out that it's unknown whether pharmacotherapy would improve fracture risk more than 5 years down the road.

“If we start treating the patient with a T score of −2 when she is 50 years old, maybe we won't change her fracture rate in the next 5 years, but at 65 will she have a reduced risk for fracture? That is a big unknown,” she said.

SANTA BARBARA, CALIF. — While it's well known that bone mineral density testing should be routine for women over the age of 65, it can be difficult to decide whether to test other patients and difficult to know what to do with the results, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

The International Society for Clinical Densitometry and the National Osteoporosis Foundation list similar indications for testing bone mineral density (BMD), said Dr. Lukert of the University of Kansas Medical Center, Kansas City. While these guidelines appear straightforward, there are complexities.

The guidelines say that in addition to all women over 65, postmenopausal women under 65 with risk factors should be tested. But studies have not succeeded in identifying all of those risk factors, so in Dr. Lukert's view it's probably prudent to measure BMD in all postmenopausal women.

Premenopausal women, on the other hand, should not have their BMD measured routinely.

The guidelines also call for BMD testing in men over 70. “We know very little about the development of osteoporosis in men, except that we do know that it's much more common than we had previously thought,” Dr. Lukert said. “We aren't measuring bone density in men frequently enough.”

Similarly, the guidelines call for BMD testing in any adult who has had a fragility fracture, but in practice this is done only about 15% of the time, an oversight that Dr. Lukert described as “appalling.”

BMD testing should also be done in adults with any disease or condition associated with bone loss or low bone mass. The conditions include Cushing's disease, hyperthyroidism, hyperparathyroidism, and rheumatoid arthritis.

Some medications are associated with bone loss, most notably the glucocorticoids, and the guidelines say that any adult taking one of these medications should have BMD testing.

Any adult who's being considered for pharmacologic therapy for bone loss should have his or her BMD assessed, and anyone receiving that therapy should have BMD testing to monitor the treatment effect.

One complexity comes in interpreting the BMD results in some of these groups. For postmenopausal women one typically uses the T score, which compares the individual's BMD to a healthy young adult's. The T score is expressed in terms of the number of standard deviations the individual's BMD falls above or below this norm. The World Health Organization defines osteoporosis as a T score of -2.5 or below, and osteopenia as a T score between −1 and −2.5.

But in premenopausal women, men aged 50–64 with no risk factors, and in men aged 20–50 with risk factors, the use of T scores can be misleading. Instead, one should use the z score, which compares an individual's BMD with that of an age-matched sample. The use of T scores would imply a relationship with fracture risk that may not exist or may differ from group to group. A postmenopausal woman with a certain BMD would have many times the fracture risk of a premenopausal woman with the same BMD.

Once one has a T score or z score, the question becomes whether to treat the patient's osteoporosis or osteopenia. The National Osteoporosis Foundation recommends treating all women with a T score of -2 or below, and women with at least one additional risk factor and a T score of −1.5 or below.

On the other hand, a recent study determined that it was not cost effective to treat osteopenic women because treatment does not significantly reduce their fracture risk over a 5-year period (Ann. Intern. Med. 2005;142:734–41).

But Dr. Lukert pointed out that it's unknown whether pharmacotherapy would improve fracture risk more than 5 years down the road.

“If we start treating the patient with a T score of −2 when she is 50 years old, maybe we won't change her fracture rate in the next 5 years, but at 65 will she have a reduced risk for fracture? That is a big unknown,” she said.

SANTA BARBARA, CALIF. — While it's well known that bone mineral density testing should be routine for women over the age of 65, it can be difficult to decide whether to test other patients and difficult to know what to do with the results, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

The International Society for Clinical Densitometry and the National Osteoporosis Foundation list similar indications for testing bone mineral density (BMD), said Dr. Lukert of the University of Kansas Medical Center, Kansas City. While these guidelines appear straightforward, there are complexities.

The guidelines say that in addition to all women over 65, postmenopausal women under 65 with risk factors should be tested. But studies have not succeeded in identifying all of those risk factors, so in Dr. Lukert's view it's probably prudent to measure BMD in all postmenopausal women.

Premenopausal women, on the other hand, should not have their BMD measured routinely.

The guidelines also call for BMD testing in men over 70. “We know very little about the development of osteoporosis in men, except that we do know that it's much more common than we had previously thought,” Dr. Lukert said. “We aren't measuring bone density in men frequently enough.”

Similarly, the guidelines call for BMD testing in any adult who has had a fragility fracture, but in practice this is done only about 15% of the time, an oversight that Dr. Lukert described as “appalling.”

BMD testing should also be done in adults with any disease or condition associated with bone loss or low bone mass. The conditions include Cushing's disease, hyperthyroidism, hyperparathyroidism, and rheumatoid arthritis.

Some medications are associated with bone loss, most notably the glucocorticoids, and the guidelines say that any adult taking one of these medications should have BMD testing.

Any adult who's being considered for pharmacologic therapy for bone loss should have his or her BMD assessed, and anyone receiving that therapy should have BMD testing to monitor the treatment effect.

One complexity comes in interpreting the BMD results in some of these groups. For postmenopausal women one typically uses the T score, which compares the individual's BMD to a healthy young adult's. The T score is expressed in terms of the number of standard deviations the individual's BMD falls above or below this norm. The World Health Organization defines osteoporosis as a T score of -2.5 or below, and osteopenia as a T score between −1 and −2.5.

But in premenopausal women, men aged 50–64 with no risk factors, and in men aged 20–50 with risk factors, the use of T scores can be misleading. Instead, one should use the z score, which compares an individual's BMD with that of an age-matched sample. The use of T scores would imply a relationship with fracture risk that may not exist or may differ from group to group. A postmenopausal woman with a certain BMD would have many times the fracture risk of a premenopausal woman with the same BMD.

Once one has a T score or z score, the question becomes whether to treat the patient's osteoporosis or osteopenia. The National Osteoporosis Foundation recommends treating all women with a T score of -2 or below, and women with at least one additional risk factor and a T score of −1.5 or below.

On the other hand, a recent study determined that it was not cost effective to treat osteopenic women because treatment does not significantly reduce their fracture risk over a 5-year period (Ann. Intern. Med. 2005;142:734–41).

But Dr. Lukert pointed out that it's unknown whether pharmacotherapy would improve fracture risk more than 5 years down the road.

“If we start treating the patient with a T score of −2 when she is 50 years old, maybe we won't change her fracture rate in the next 5 years, but at 65 will she have a reduced risk for fracture? That is a big unknown,” she said.