Robert Finn

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 proton 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 a number of important parameters of cardiac function. (See box.) 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 especially 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. On the one hand, studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy. On the other hand, patients with less than about 10% ischemia have a lower risk of cardiac death with medical therapy.

Despite its value, cardiac perfusion SPECT does have a number of limitations, Dr. Berman said. Because the test detects only hydrodynamically significant lesions, it won't pick up early atherosclerosis. It also won't pick up some of the patients at the very highest risk, those with a balanced reduction in perfusion. And it may underestimate the extent of ischemia and cardiovascular disease as well as the amount of viable myocardium.

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 proton 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 a number of important parameters of cardiac function. (See box.) 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 especially 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. On the one hand, studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy. On the other hand, patients with less than about 10% ischemia have a lower risk of cardiac death with medical therapy.

Despite its value, cardiac perfusion SPECT does have a number of limitations, Dr. Berman said. Because the test detects only hydrodynamically significant lesions, it won't pick up early atherosclerosis. It also won't pick up some of the patients at the very highest risk, those with a balanced reduction in perfusion. And it may underestimate the extent of ischemia and cardiovascular disease as well as the amount of viable myocardium.

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 proton 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 a number of important parameters of cardiac function. (See box.) 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 especially 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. On the one hand, studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy. On the other hand, patients with less than about 10% ischemia have a lower risk of cardiac death with medical therapy.

Despite its value, cardiac perfusion SPECT does have a number of limitations, Dr. Berman said. Because the test detects only hydrodynamically significant lesions, it won't pick up early atherosclerosis. It also won't pick up some of the patients at the very highest risk, those with a balanced reduction in perfusion. And it may underestimate the extent of ischemia and cardiovascular disease as well as the amount of viable myocardium.

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 — With computed tomography angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., remarked at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath. The entire procedure takes 20 minutes, and interpretation takes another 10 minutes.

Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today.

And these workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Now, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%.

Most important, the negative predictive value is 98%–100%. “The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” Dr. Budoff said.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability. Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. With multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second. This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible. Other clinical indications for CT angiography are in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. It's not very good for visualizing vessels with diameters less than 1.5 mm. It is subject to artifacts from extensive calcification, stents, or extensive clips after bypass grafting. And it subjects patients to a relatively high dose of radiation—about 9.3–11.3 mSv, compared with 2.1–2.3 mSv for the cath lab and 0.1 mSv for a chest x-ray.

CT angiography reveales high-grade stenosis (dark area) in the mid-left anterior descending coronary artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — With computed tomography angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., remarked at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath. The entire procedure takes 20 minutes, and interpretation takes another 10 minutes.

Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today.

And these workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Now, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%.

Most important, the negative predictive value is 98%–100%. “The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” Dr. Budoff said.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability. Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. With multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second. This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible. Other clinical indications for CT angiography are in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. It's not very good for visualizing vessels with diameters less than 1.5 mm. It is subject to artifacts from extensive calcification, stents, or extensive clips after bypass grafting. And it subjects patients to a relatively high dose of radiation—about 9.3–11.3 mSv, compared with 2.1–2.3 mSv for the cath lab and 0.1 mSv for a chest x-ray.

CT angiography reveales high-grade stenosis (dark area) in the mid-left anterior descending coronary artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — With computed tomography angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., remarked at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath. The entire procedure takes 20 minutes, and interpretation takes another 10 minutes.

Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today.

And these workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Now, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%.

Most important, the negative predictive value is 98%–100%. “The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” Dr. Budoff said.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability. Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. With multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second. This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible. Other clinical indications for CT angiography are in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. It's not very good for visualizing vessels with diameters less than 1.5 mm. It is subject to artifacts from extensive calcification, stents, or extensive clips after bypass grafting. And it subjects patients to a relatively high dose of radiation—about 9.3–11.3 mSv, compared with 2.1–2.3 mSv for the cath lab and 0.1 mSv for a chest x-ray.

CT angiography reveales high-grade stenosis (dark area) in the mid-left anterior descending coronary artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — The goal of antidepressant treatment should be remission, but most clinical trials use a 50% response in 50% of patients as the criterion for effectiveness. Only about 20%–30% of patients achieve complete remission, and this suggests that additional treatment will be necessary, Jeffrey M. Levine, M.D., said at the annual meeting of the American College of Physicians.

But before changing a patient's selective serotonin reuptake inhibitor (SSRI) prescription because of an incomplete response, physicians should consider a series of questions, said Dr. Levine of the Albert Einstein College of Medicine, New York.

First, determine whether the patient is taking the medication. Studies indicate that about 50% of SSRI prescriptions are filled only once. In addition, find out whether the patient is using alcohol or illicit drugs.

Next, use this as an opportunity to review relevant medical issues. Has the patient had recent thyroid function and HIV tests? Is he or she taking any other medications, such as glucocorticoids, β-blockers, or fluoroquinolones that could affect depression treatment? Has the patient been evaluated for sleep apnea?

It may be productive to employ the systematic approach suggested by the mnemonic CITTENNS for possible causes of altered mental status. CITTENNS stands for cardiorespiratory, infectious, toxic, traumatic, endocrine/metabolic, neurologic, neoplastic, and systemic/autoimmune.

Ask about domestic violence, ongoing safety issues, or threats to the patient. “If a patient is being abused or threatened by a partner, your antidepressants are not going to make [him or her] better,” Dr. Levine said.

Consider whether the patient may have something to gain from depression. “If a patient has a comp case or a disability case going at this moment, it may be irrelevant or it may be very relevant.” Dr. Levine said. “It may just not be the time they're going to get better.”

Consider the possibility that the patient has bipolar disorder. Although it may seem as if it would be difficult to confuse mania with depression, recent studies have shown that about a third of patients with bipolar disorder are depressed at the time they're manic. In this mixed state, the patient may complain about depression but have features of mania, such as agitation, pressured speech, racing thoughts, and an inability to sleep.

If the physician answers all of those questions to his or her satisfaction, and the patient still has an incomplete SSRI response, the patient should be given a trial at the maximal dose: 40–60 mg of fluoxetine, 150–200 mg of sertraline, 40–50 mg of paroxetine, or 20 mg of escitalopram, for example.

If that doesn't work, there's little point in trying a different SSRI. Instead, one should either switch to a combined serotonin norepinephrine reuptake inhibitor such as venlafaxine or duloxetine, or add bupropion or mirtazapine.

Bupropion is contraindicated in patients with eating disorders or a history of seizures, but may be especially useful in the patient who reports a lack of energy.

Mirtazapine can increase appetite and cause weight gain, which may or may not be desirable, and has a strong sleep-enhancing effect.

If the addition of a norepinephrine agent doesn't work, the next step would be a low dose of a second-generation antipsychotic such as 0.5–2 mg of risperidone or 5–15 mg of olanzapine. This step is problematic for patients who have type 2 diabetes or are at risk for this condition.

In patients with possible bipolar disorder, lithium or lamotrigine can be useful.

Finally, electroconvulsive therapy might be considered in patients with persistent psychosis, continued suicidality, profound psychomotor retardation, or profound anhedonia.

Dr. Levine disclosed serving on the speakers' bureau for Pfizer Inc.

SAN FRANCISCO — The goal of antidepressant treatment should be remission, but most clinical trials use a 50% response in 50% of patients as the criterion for effectiveness. Only about 20%–30% of patients achieve complete remission, and this suggests that additional treatment will be necessary, Jeffrey M. Levine, M.D., said at the annual meeting of the American College of Physicians.

But before changing a patient's selective serotonin reuptake inhibitor (SSRI) prescription because of an incomplete response, physicians should consider a series of questions, said Dr. Levine of the Albert Einstein College of Medicine, New York.

First, determine whether the patient is taking the medication. Studies indicate that about 50% of SSRI prescriptions are filled only once. In addition, find out whether the patient is using alcohol or illicit drugs.

Next, use this as an opportunity to review relevant medical issues. Has the patient had recent thyroid function and HIV tests? Is he or she taking any other medications, such as glucocorticoids, β-blockers, or fluoroquinolones that could affect depression treatment? Has the patient been evaluated for sleep apnea?

It may be productive to employ the systematic approach suggested by the mnemonic CITTENNS for possible causes of altered mental status. CITTENNS stands for cardiorespiratory, infectious, toxic, traumatic, endocrine/metabolic, neurologic, neoplastic, and systemic/autoimmune.

Ask about domestic violence, ongoing safety issues, or threats to the patient. “If a patient is being abused or threatened by a partner, your antidepressants are not going to make [him or her] better,” Dr. Levine said.

Consider whether the patient may have something to gain from depression. “If a patient has a comp case or a disability case going at this moment, it may be irrelevant or it may be very relevant.” Dr. Levine said. “It may just not be the time they're going to get better.”

Consider the possibility that the patient has bipolar disorder. Although it may seem as if it would be difficult to confuse mania with depression, recent studies have shown that about a third of patients with bipolar disorder are depressed at the time they're manic. In this mixed state, the patient may complain about depression but have features of mania, such as agitation, pressured speech, racing thoughts, and an inability to sleep.

If the physician answers all of those questions to his or her satisfaction, and the patient still has an incomplete SSRI response, the patient should be given a trial at the maximal dose: 40–60 mg of fluoxetine, 150–200 mg of sertraline, 40–50 mg of paroxetine, or 20 mg of escitalopram, for example.

If that doesn't work, there's little point in trying a different SSRI. Instead, one should either switch to a combined serotonin norepinephrine reuptake inhibitor such as venlafaxine or duloxetine, or add bupropion or mirtazapine.

Bupropion is contraindicated in patients with eating disorders or a history of seizures, but may be especially useful in the patient who reports a lack of energy.

Mirtazapine can increase appetite and cause weight gain, which may or may not be desirable, and has a strong sleep-enhancing effect.

If the addition of a norepinephrine agent doesn't work, the next step would be a low dose of a second-generation antipsychotic such as 0.5–2 mg of risperidone or 5–15 mg of olanzapine. This step is problematic for patients who have type 2 diabetes or are at risk for this condition.

In patients with possible bipolar disorder, lithium or lamotrigine can be useful.

Finally, electroconvulsive therapy might be considered in patients with persistent psychosis, continued suicidality, profound psychomotor retardation, or profound anhedonia.

Dr. Levine disclosed serving on the speakers' bureau for Pfizer Inc.

SAN FRANCISCO — The goal of antidepressant treatment should be remission, but most clinical trials use a 50% response in 50% of patients as the criterion for effectiveness. Only about 20%–30% of patients achieve complete remission, and this suggests that additional treatment will be necessary, Jeffrey M. Levine, M.D., said at the annual meeting of the American College of Physicians.

But before changing a patient's selective serotonin reuptake inhibitor (SSRI) prescription because of an incomplete response, physicians should consider a series of questions, said Dr. Levine of the Albert Einstein College of Medicine, New York.

First, determine whether the patient is taking the medication. Studies indicate that about 50% of SSRI prescriptions are filled only once. In addition, find out whether the patient is using alcohol or illicit drugs.

Next, use this as an opportunity to review relevant medical issues. Has the patient had recent thyroid function and HIV tests? Is he or she taking any other medications, such as glucocorticoids, β-blockers, or fluoroquinolones that could affect depression treatment? Has the patient been evaluated for sleep apnea?

It may be productive to employ the systematic approach suggested by the mnemonic CITTENNS for possible causes of altered mental status. CITTENNS stands for cardiorespiratory, infectious, toxic, traumatic, endocrine/metabolic, neurologic, neoplastic, and systemic/autoimmune.

Ask about domestic violence, ongoing safety issues, or threats to the patient. “If a patient is being abused or threatened by a partner, your antidepressants are not going to make [him or her] better,” Dr. Levine said.

Consider whether the patient may have something to gain from depression. “If a patient has a comp case or a disability case going at this moment, it may be irrelevant or it may be very relevant.” Dr. Levine said. “It may just not be the time they're going to get better.”

Consider the possibility that the patient has bipolar disorder. Although it may seem as if it would be difficult to confuse mania with depression, recent studies have shown that about a third of patients with bipolar disorder are depressed at the time they're manic. In this mixed state, the patient may complain about depression but have features of mania, such as agitation, pressured speech, racing thoughts, and an inability to sleep.

If the physician answers all of those questions to his or her satisfaction, and the patient still has an incomplete SSRI response, the patient should be given a trial at the maximal dose: 40–60 mg of fluoxetine, 150–200 mg of sertraline, 40–50 mg of paroxetine, or 20 mg of escitalopram, for example.

If that doesn't work, there's little point in trying a different SSRI. Instead, one should either switch to a combined serotonin norepinephrine reuptake inhibitor such as venlafaxine or duloxetine, or add bupropion or mirtazapine.

Bupropion is contraindicated in patients with eating disorders or a history of seizures, but may be especially useful in the patient who reports a lack of energy.

Mirtazapine can increase appetite and cause weight gain, which may or may not be desirable, and has a strong sleep-enhancing effect.

If the addition of a norepinephrine agent doesn't work, the next step would be a low dose of a second-generation antipsychotic such as 0.5–2 mg of risperidone or 5–15 mg of olanzapine. This step is problematic for patients who have type 2 diabetes or are at risk for this condition.

In patients with possible bipolar disorder, lithium or lamotrigine can be useful.

Finally, electroconvulsive therapy might be considered in patients with persistent psychosis, continued suicidality, profound psychomotor retardation, or profound anhedonia.

Dr. Levine disclosed serving on the speakers' bureau for Pfizer Inc.

SAN FRANCISCO — Atopic dermatitis is a multifactorial disease requiring multimodal treatment, Jeffrey Sugarman, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

Dr. Sugarman of the university offered a number of tips to assist the clinician in treating atopic dermatitis (AD), the key dermatosis in children:

▸ Be sure of the diagnosis. “Pruritus is a universal feature,” Dr. Sugarman said. “If your child with atopic dermatitis is not itchy, you may want to rethink the diagnosis.”

▸ Barrier dysfunction contributes to AD, and the barrier is typically abnormal, even in nonlesional skin. This results in an increased permeability to bacterial pathogens, allergens, and nonspecific irritants.

▸ Gentle skin care is important, and one way to accomplish that is to use a cleanser with a neutral or slightly acidic pH. Surprisingly, some popular cleansers, even those marketed for infants, have highly alkaline pH, which exacerbates barrier dysfunction. (See chart.)

▸ Recommend the use of emollients, hydrophobic lipids that replace or supplement subcutaneous lipids. These form a temporary hydrophobic shield on the surface, which promotes immediate barrier repair.

▸ Most emollients, such as petrolatum and lanolin, are nonphysiologic and have a limited duration of benefit (less than 6 hours).

Physiologic lipid emollients, which now are coming on the market, contain correct molar ratios of ceramide, cholesterol, and free fatty acids.

The skin handles physiologic emollients differently than their nonphysiologic counterparts. Physiologic emollients are taken up by keratinocytes, packaged into lamellar bodies, and resecreted to form lamellar bilayers.

TriCeram is one such emollient that's already on the market, and Dr. Sugarman expects others to become available soon. Unfortunately, the high price of TriCeram will put it out of the reach of many patients, he said.

▸ “Drooling dermatitis,” AD around an infant's mouth, is caused by mechanical irritation in messy eaters from nursing or the bottle. Tell parents to keep the barrier up by applying Vaseline or Aquaphor on the perioral skin before meals. Assure them that drooling dermatitis will disappear as the infant gets older.

▸ A child or adolescent who has had “athlete's foot” that has not responded to topical antifungals may actually have juvenile plantar dermatosis or “toxic sock syndrome,” he said.

These children typically will have sweaty feet and a history of atopic disease. Look closely at the bottom of the feet. Juvenile plantar dermatosis is characterized by inflammation on the weight-bearing surfaces of the big toes.

The web spaces are spared, which is the opposite distribution you would see from a fungal infection. Treatment includes a frequent change of socks and the use of emollients and a mid-potency steroid cream.

▸ To minimize pruritus with AD, recommend warm—not hot—baths, and avoid overheating. Keep the body covered with soft, non-wool clothing. Use emollients. Hydroxyzine is Dr. Sugarman's favored antihistamine, at a dose of 1–2 mg/kg per day.

Consider rotating antihistamines, such as cyproheptadine, doxepin, and diphenhydramine, if one stops working. Topical diphenhydramine is of little use, and the newer nonsedating antihistamines also appear to be relatively ineffective in reducing pruritus.

▸ For decades, the use of intermittent topical corticosteroids has been the standard of care for AD, despite their well-known side effects including burning, redness, dryness, and thinning of skin with long-term use.

▸ Topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus also work, and are especially valuable for intertriginous and eyelid lesions. They decrease the need for topical corticosteroids and improve quality of life.

The FDA apparently is concerned about the potential risk of cancer with long-term use of TCIs, but Dr. Sugarman said they're safe if used properly.

They should be reserved for second-line use for short-term and intermittent long-term use in AD. TCIs should be avoided in children younger than age 2 and in immunocompromised patients. Reinforce the need for adjunctive treatment such as gentle skin care, controlling itch, and treating infections. And advise parents that treated areas also need sun protection.

SAN FRANCISCO — Atopic dermatitis is a multifactorial disease requiring multimodal treatment, Jeffrey Sugarman, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

Dr. Sugarman of the university offered a number of tips to assist the clinician in treating atopic dermatitis (AD), the key dermatosis in children:

▸ Be sure of the diagnosis. “Pruritus is a universal feature,” Dr. Sugarman said. “If your child with atopic dermatitis is not itchy, you may want to rethink the diagnosis.”

▸ Barrier dysfunction contributes to AD, and the barrier is typically abnormal, even in nonlesional skin. This results in an increased permeability to bacterial pathogens, allergens, and nonspecific irritants.

▸ Gentle skin care is important, and one way to accomplish that is to use a cleanser with a neutral or slightly acidic pH. Surprisingly, some popular cleansers, even those marketed for infants, have highly alkaline pH, which exacerbates barrier dysfunction. (See chart.)

▸ Recommend the use of emollients, hydrophobic lipids that replace or supplement subcutaneous lipids. These form a temporary hydrophobic shield on the surface, which promotes immediate barrier repair.

▸ Most emollients, such as petrolatum and lanolin, are nonphysiologic and have a limited duration of benefit (less than 6 hours).

Physiologic lipid emollients, which now are coming on the market, contain correct molar ratios of ceramide, cholesterol, and free fatty acids.

The skin handles physiologic emollients differently than their nonphysiologic counterparts. Physiologic emollients are taken up by keratinocytes, packaged into lamellar bodies, and resecreted to form lamellar bilayers.

TriCeram is one such emollient that's already on the market, and Dr. Sugarman expects others to become available soon. Unfortunately, the high price of TriCeram will put it out of the reach of many patients, he said.

▸ “Drooling dermatitis,” AD around an infant's mouth, is caused by mechanical irritation in messy eaters from nursing or the bottle. Tell parents to keep the barrier up by applying Vaseline or Aquaphor on the perioral skin before meals. Assure them that drooling dermatitis will disappear as the infant gets older.

▸ A child or adolescent who has had “athlete's foot” that has not responded to topical antifungals may actually have juvenile plantar dermatosis or “toxic sock syndrome,” he said.

These children typically will have sweaty feet and a history of atopic disease. Look closely at the bottom of the feet. Juvenile plantar dermatosis is characterized by inflammation on the weight-bearing surfaces of the big toes.

The web spaces are spared, which is the opposite distribution you would see from a fungal infection. Treatment includes a frequent change of socks and the use of emollients and a mid-potency steroid cream.

▸ To minimize pruritus with AD, recommend warm—not hot—baths, and avoid overheating. Keep the body covered with soft, non-wool clothing. Use emollients. Hydroxyzine is Dr. Sugarman's favored antihistamine, at a dose of 1–2 mg/kg per day.

Consider rotating antihistamines, such as cyproheptadine, doxepin, and diphenhydramine, if one stops working. Topical diphenhydramine is of little use, and the newer nonsedating antihistamines also appear to be relatively ineffective in reducing pruritus.

▸ For decades, the use of intermittent topical corticosteroids has been the standard of care for AD, despite their well-known side effects including burning, redness, dryness, and thinning of skin with long-term use.

▸ Topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus also work, and are especially valuable for intertriginous and eyelid lesions. They decrease the need for topical corticosteroids and improve quality of life.

The FDA apparently is concerned about the potential risk of cancer with long-term use of TCIs, but Dr. Sugarman said they're safe if used properly.

They should be reserved for second-line use for short-term and intermittent long-term use in AD. TCIs should be avoided in children younger than age 2 and in immunocompromised patients. Reinforce the need for adjunctive treatment such as gentle skin care, controlling itch, and treating infections. And advise parents that treated areas also need sun protection.

SAN FRANCISCO — Atopic dermatitis is a multifactorial disease requiring multimodal treatment, Jeffrey Sugarman, M.D., said at a meeting on clinical pediatrics sponsored by the University of California, San Francisco.

Dr. Sugarman of the university offered a number of tips to assist the clinician in treating atopic dermatitis (AD), the key dermatosis in children:

▸ Be sure of the diagnosis. “Pruritus is a universal feature,” Dr. Sugarman said. “If your child with atopic dermatitis is not itchy, you may want to rethink the diagnosis.”

▸ Barrier dysfunction contributes to AD, and the barrier is typically abnormal, even in nonlesional skin. This results in an increased permeability to bacterial pathogens, allergens, and nonspecific irritants.

▸ Gentle skin care is important, and one way to accomplish that is to use a cleanser with a neutral or slightly acidic pH. Surprisingly, some popular cleansers, even those marketed for infants, have highly alkaline pH, which exacerbates barrier dysfunction. (See chart.)

▸ Recommend the use of emollients, hydrophobic lipids that replace or supplement subcutaneous lipids. These form a temporary hydrophobic shield on the surface, which promotes immediate barrier repair.

▸ Most emollients, such as petrolatum and lanolin, are nonphysiologic and have a limited duration of benefit (less than 6 hours).

Physiologic lipid emollients, which now are coming on the market, contain correct molar ratios of ceramide, cholesterol, and free fatty acids.

The skin handles physiologic emollients differently than their nonphysiologic counterparts. Physiologic emollients are taken up by keratinocytes, packaged into lamellar bodies, and resecreted to form lamellar bilayers.

TriCeram is one such emollient that's already on the market, and Dr. Sugarman expects others to become available soon. Unfortunately, the high price of TriCeram will put it out of the reach of many patients, he said.

▸ “Drooling dermatitis,” AD around an infant's mouth, is caused by mechanical irritation in messy eaters from nursing or the bottle. Tell parents to keep the barrier up by applying Vaseline or Aquaphor on the perioral skin before meals. Assure them that drooling dermatitis will disappear as the infant gets older.

▸ A child or adolescent who has had “athlete's foot” that has not responded to topical antifungals may actually have juvenile plantar dermatosis or “toxic sock syndrome,” he said.

These children typically will have sweaty feet and a history of atopic disease. Look closely at the bottom of the feet. Juvenile plantar dermatosis is characterized by inflammation on the weight-bearing surfaces of the big toes.

The web spaces are spared, which is the opposite distribution you would see from a fungal infection. Treatment includes a frequent change of socks and the use of emollients and a mid-potency steroid cream.

▸ To minimize pruritus with AD, recommend warm—not hot—baths, and avoid overheating. Keep the body covered with soft, non-wool clothing. Use emollients. Hydroxyzine is Dr. Sugarman's favored antihistamine, at a dose of 1–2 mg/kg per day.

Consider rotating antihistamines, such as cyproheptadine, doxepin, and diphenhydramine, if one stops working. Topical diphenhydramine is of little use, and the newer nonsedating antihistamines also appear to be relatively ineffective in reducing pruritus.

▸ For decades, the use of intermittent topical corticosteroids has been the standard of care for AD, despite their well-known side effects including burning, redness, dryness, and thinning of skin with long-term use.

▸ Topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus also work, and are especially valuable for intertriginous and eyelid lesions. They decrease the need for topical corticosteroids and improve quality of life.

The FDA apparently is concerned about the potential risk of cancer with long-term use of TCIs, but Dr. Sugarman said they're safe if used properly.

They should be reserved for second-line use for short-term and intermittent long-term use in AD. TCIs should be avoided in children younger than age 2 and in immunocompromised patients. Reinforce the need for adjunctive treatment such as gentle skin care, controlling itch, and treating infections. And advise parents that treated areas also need sun protection.

SAN FRANCISCO — With CT angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath.

The entire procedure takes 20 minutes, and interpretation takes another 10 minutes. Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today. In addtion, these new workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three of their major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Nowadays, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%. Most important, the negative predictive value is 98%–100%.

“The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” according to Dr. Budoff.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability. Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. If there's a regular rhythm, with multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second. This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible. Other clinical indications for CT angiography are: in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. Not only is it not very good for visualizing vessels with diameters less than 1.5 mm, it is also subject to artifacts deriving from extensive calcification, stents, or extensive clips after bypass grafting.

High grade stenosis (dark area) is in the mid-left anterior descending artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — With CT angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath.

The entire procedure takes 20 minutes, and interpretation takes another 10 minutes. Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today. In addtion, these new workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three of their major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Nowadays, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%. Most important, the negative predictive value is 98%–100%.

“The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” according to Dr. Budoff.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability. Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. If there's a regular rhythm, with multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second. This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible. Other clinical indications for CT angiography are: in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. Not only is it not very good for visualizing vessels with diameters less than 1.5 mm, it is also subject to artifacts deriving from extensive calcification, stents, or extensive clips after bypass grafting.

High grade stenosis (dark area) is in the mid-left anterior descending artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — With CT angiography, “patients literally go home with a Band-Aid and a bottle of water” after just 20 minutes, Matthew J. Budoff, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

With high sensitivity and specificity and images that rival the resolution obtainable with traditional coronary angiography from the catheterization lab, CT angiography will allow many more patients to avoid an invasive procedure, said Dr. Budoff of Harbor-UCLA Medical Center, Torrance, Calif.

After an injection of 80–100 mL of nonionic iodinated contrast solution, up to 4,000 two-dimensional images can be obtained within 20–30 seconds as the patient holds his or her breath.

The entire procedure takes 20 minutes, and interpretation takes another 10 minutes. Sophisticated workstations assemble the stack of 2D images into a three-dimensional reconstruction. Interpretations are made on the basis of the 3D reconstruction with reference to the 2D images.

Dr. Budoff started working with CT angiography in the mid-1990s. In those days it took 3 weeks of full-time computation to assemble a single 3D reconstruction. This same function takes just 30 seconds today. In addtion, these new workstations allow the cardiologist to rotate the heart image in three dimensions, to zoom in to interesting features, and to easily reference the original 2D data from any point of interest.

The initial studies of four-slice CT angiography revealed the limitations of this early technique. Only 30% of patients had all three of their major arteries available for analysis, and in detecting stenosis the sensitivity was just 58% with 76% specificity.

Nowadays, as 16-slice and even 64-slice CT angiography become available, the sensitivity and specificity have improved considerably. Studies have calculated sensitivities as high as 97% and specificities as high as 94%. Most important, the negative predictive value is 98%–100%.

“The benefit of CT angio is that when the coronaries look normal, the coronaries are normal,” according to Dr. Budoff.

The temporal resolution of the CT images is about 175 milliseconds, so reducing the heart rate to below 60 beats per minute is important for accuracy and interpretability. Most centers use 100 mg metoprolol 1 hour prior to the study and/or a 5-mg intravenous metoprolol push every 5 minutes until the patient achieves a slow heart rate.

A regular rhythm is also important. If there's a regular rhythm, with multiple detectors obtaining images at specific parts of the heart cycle, the modality reaches an effective frame speed of 15 images per second. This is slower than the cath lab, but fast enough that the images are free of motion artifact.

CT angiography may be the best technique for imaging the results of bypass grafting as the anastomoses are clearly visible. Other clinical indications for CT angiography are: in cases of equivocal results following stress testing; to evaluate patency post angioplasty, post stent, and post bypass surgery; in cases of congenital abnormalities and anomalous coronaries; before and after atrial fibrillation ablation; and before placing a biventricular pacer.

CT angiography is not without its disadvantages, however. Not only is it not very good for visualizing vessels with diameters less than 1.5 mm, it is also subject to artifacts deriving from extensive calcification, stents, or extensive clips after bypass grafting.

High grade stenosis (dark area) is in the mid-left anterior descending artery. Courtesy Dr. Matthew J. Budoff

SAN FRANCISCO — Cardiac MRI 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—does have its advantages, cardiac magnetic resonance (CMR) provides outstanding image quality, excellent quantification, and tissue characterization, said Dr. Kramer of the University of Virginia, in Charlottesville.

Gadolinium contrast, which is easy to use and safe with CMR, also offers the ability to assess intramural function.

On the other hand, 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 MRI 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—does have its advantages, cardiac magnetic resonance (CMR) provides outstanding image quality, excellent quantification, and tissue characterization, said Dr. Kramer of the University of Virginia, in Charlottesville.

Gadolinium contrast, which is easy to use and safe with CMR, also offers the ability to assess intramural function.

On the other hand, 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 MRI 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—does have its advantages, cardiac magnetic resonance (CMR) provides outstanding image quality, excellent quantification, and tissue characterization, said Dr. Kramer of the University of Virginia, in Charlottesville.

Gadolinium contrast, which is easy to use and safe with CMR, also offers the ability to assess intramural function.

On the other hand, 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.

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 should be tested if they have any risk factors. 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.

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 any adult taking one of these medications should have BMD testing.

Any adult who is 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.

“If we follow these indications, we would greatly increase the number of patients who are having their bone density measured,” Dr. Lukert said.

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 that of a healthy young adult.

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, 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.”

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 should be tested if they have any risk factors. 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.

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 any adult taking one of these medications should have BMD testing.

Any adult who is 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.

“If we follow these indications, we would greatly increase the number of patients who are having their bone density measured,” Dr. Lukert said.

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 that of a healthy young adult.

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, 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.”

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 should be tested if they have any risk factors. 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.

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 any adult taking one of these medications should have BMD testing.

Any adult who is 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.

“If we follow these indications, we would greatly increase the number of patients who are having their bone density measured,” Dr. Lukert said.

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 that of a healthy young adult.

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, 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.”

SANTA BARBARA, CALIF. — About half of patients using glucocorticoids for long periods will suffer compression fractures of the vertebrae if nothing is done to intervene, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

Bisphosphonate therapy is clearly effective in reducing fractures, whether started when initiating glucocorticoids or after a patient has been on them for a while.

But bisphosphonates aren't enough, and other steps should be taken to manage these patients, said Dr. Lukert of the University of Kansas Medical Center in Kansas City.

Other opportunities to intervene are listed below:

▸ Diet is critical. Since glucocorticoids are catabolic, patients need adequate protein intake, not just calcium and phosphorus.

▸ Heavily encourage patients to exercise, not only because of its benefits on bone. Glucocorticoids often cause myopathy, ranging from mild to severe, and exercise can help to offset this. Strengthening the quadriceps and related muscle groups also has been shown to help prevent falls.

▸ Control urinary calcium. A very large percentage of patients who use glucocorticoids will develop hypercalciuria, and restricting sodium in the diet will go a long way toward resolving this.

▸ Replace hormones as appropriate. Women taking steroids often have low estrogen levels. If premenopausal women become amenorrheic on glucocorticoids, consider prescribing estrogen or progesterone. Dr. Lukert noted that estrogen replacement in postmenopausal women remains controversial.

Patients who have a bone mineral density (BMD) T score of less than -1.5 or are taking more than 10 mg/day of prednisone or the equivalent should receive bisphosphonates as soon as corticosteroids are started.

Patients with a higher BMD taking lower doses of prednisone may hold off on starting bisphosphonates at first and retest BMD after 6 months.

Another reasonable strategy is simply to give a bisphosphonate to all patients who anticipate taking steroids for several weeks or longer.

This strategy is certain to prevent fractures, but at the cost of treating 40%–50% of patients who probably would not have suffered a fracture, even without the bisphosphonate prescription.

SANTA BARBARA, CALIF. — About half of patients using glucocorticoids for long periods will suffer compression fractures of the vertebrae if nothing is done to intervene, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

Bisphosphonate therapy is clearly effective in reducing fractures, whether started when initiating glucocorticoids or after a patient has been on them for a while.

But bisphosphonates aren't enough, and other steps should be taken to manage these patients, said Dr. Lukert of the University of Kansas Medical Center in Kansas City.

Other opportunities to intervene are listed below:

▸ Diet is critical. Since glucocorticoids are catabolic, patients need adequate protein intake, not just calcium and phosphorus.

▸ Heavily encourage patients to exercise, not only because of its benefits on bone. Glucocorticoids often cause myopathy, ranging from mild to severe, and exercise can help to offset this. Strengthening the quadriceps and related muscle groups also has been shown to help prevent falls.

▸ Control urinary calcium. A very large percentage of patients who use glucocorticoids will develop hypercalciuria, and restricting sodium in the diet will go a long way toward resolving this.

▸ Replace hormones as appropriate. Women taking steroids often have low estrogen levels. If premenopausal women become amenorrheic on glucocorticoids, consider prescribing estrogen or progesterone. Dr. Lukert noted that estrogen replacement in postmenopausal women remains controversial.

Patients who have a bone mineral density (BMD) T score of less than -1.5 or are taking more than 10 mg/day of prednisone or the equivalent should receive bisphosphonates as soon as corticosteroids are started.

Patients with a higher BMD taking lower doses of prednisone may hold off on starting bisphosphonates at first and retest BMD after 6 months.

Another reasonable strategy is simply to give a bisphosphonate to all patients who anticipate taking steroids for several weeks or longer.

This strategy is certain to prevent fractures, but at the cost of treating 40%–50% of patients who probably would not have suffered a fracture, even without the bisphosphonate prescription.

SANTA BARBARA, CALIF. — About half of patients using glucocorticoids for long periods will suffer compression fractures of the vertebrae if nothing is done to intervene, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

Bisphosphonate therapy is clearly effective in reducing fractures, whether started when initiating glucocorticoids or after a patient has been on them for a while.

But bisphosphonates aren't enough, and other steps should be taken to manage these patients, said Dr. Lukert of the University of Kansas Medical Center in Kansas City.

Other opportunities to intervene are listed below:

▸ Diet is critical. Since glucocorticoids are catabolic, patients need adequate protein intake, not just calcium and phosphorus.

▸ Heavily encourage patients to exercise, not only because of its benefits on bone. Glucocorticoids often cause myopathy, ranging from mild to severe, and exercise can help to offset this. Strengthening the quadriceps and related muscle groups also has been shown to help prevent falls.

▸ Control urinary calcium. A very large percentage of patients who use glucocorticoids will develop hypercalciuria, and restricting sodium in the diet will go a long way toward resolving this.

▸ Replace hormones as appropriate. Women taking steroids often have low estrogen levels. If premenopausal women become amenorrheic on glucocorticoids, consider prescribing estrogen or progesterone. Dr. Lukert noted that estrogen replacement in postmenopausal women remains controversial.

Patients who have a bone mineral density (BMD) T score of less than -1.5 or are taking more than 10 mg/day of prednisone or the equivalent should receive bisphosphonates as soon as corticosteroids are started.

Patients with a higher BMD taking lower doses of prednisone may hold off on starting bisphosphonates at first and retest BMD after 6 months.

Another reasonable strategy is simply to give a bisphosphonate to all patients who anticipate taking steroids for several weeks or longer.

This strategy is certain to prevent fractures, but at the cost of treating 40%–50% of patients who probably would not have suffered a fracture, even without the bisphosphonate prescription.

SAN ANTONIO — A large longitudinal study of men who underwent radical prostatectomy has shown a small but statistically significant increase in sexual potency between 2 and 5 years after radical prostatectomy, David F. Penson, M.D., reported at the annual meeting of the American Urological Association.

On the other hand, incontinence worsened between 2 and 5 years post surgery after improving between 6 months and 2 years, according to Dr. Penson of the University of Southern California, Los Angeles.

Part of the Prostate Cancer Outcomes Study (PCOS), the population-based, longitudinal study used tumor registries to identify all men with prostate cancer in three states—Connecticut, New Mexico, and Utah—and three metropolitan areas—Atlanta, Los Angeles, and Seattle.

Dr. Penson's study included 1,288 men with localized prostate cancer who underwent radical prostatectomy. The patients completed surveys at baseline and then again at 6, 12, 24, and 60 months after surgery.

At baseline, 17% of the men reported having erections that were not firm enough for intercourse. That figure rose to 89% at 6 months following surgery and declined, thereafter, to 81% at 12 months, 75% at 24 months, and 71% at 60 months.

Discussing the study at a press briefing, Dr. Penson expressed surprise at the increase in potency between 24 and 60 months. “That's statistically significant, but it's also clinically meaningful,” he said.

He listed three possibilities for this finding:

▸ The first reason is that the study could have been inadequate. Some patients were lost to follow-up, and this may have skewed the results.

▸ The second reason is that perhaps there was a true late return of function. “That's a new idea,” Dr. Penson said. “Most urologists would say, if you're not potent by 2 years it's probably not going to get any better. Certainly that's what I've been telling my patients.”

▸ The last possibility is what Dr. Penson called the Viagra effect. Viagra became available in 1998, year 3 of the PCOS study.

Patients in the study were asked whether they tried Viagra (sildenafil), and if so, how much they thought it helped. About two-thirds of the men under age 60 at the time of surgery who tried Viagra said the drug helped somewhat or a lot. This percentage declined significantly among men over 60, however. For example, 66% of men aged 60–64 years said that Viagra didn't help at all.

The study also examined the effect of nerve-sparing surgery. As expected, bilateral nerve-sparing surgery proved to be significantly more effective at preserving potency than unilateral nerve-sparing surgery or no nerve sparing.

Bilateral nerve-sparing surgery helped younger men significantly more than older men. Among men aged 39–54 years at the time of the surgery, 71% reported erections firm enough for intercourse. But only 46% of the men aged 60–64 years and 18% of the men aged 65 and older reported that bilateral nerve-sparing surgery preserved their potency.

Dr. Penson disclosed a relationship with Pfizer Inc., maker of Viagra, as well as with several other pharmaceutical companies.

SAN ANTONIO — A large longitudinal study of men who underwent radical prostatectomy has shown a small but statistically significant increase in sexual potency between 2 and 5 years after radical prostatectomy, David F. Penson, M.D., reported at the annual meeting of the American Urological Association.

On the other hand, incontinence worsened between 2 and 5 years post surgery after improving between 6 months and 2 years, according to Dr. Penson of the University of Southern California, Los Angeles.

Part of the Prostate Cancer Outcomes Study (PCOS), the population-based, longitudinal study used tumor registries to identify all men with prostate cancer in three states—Connecticut, New Mexico, and Utah—and three metropolitan areas—Atlanta, Los Angeles, and Seattle.

Dr. Penson's study included 1,288 men with localized prostate cancer who underwent radical prostatectomy. The patients completed surveys at baseline and then again at 6, 12, 24, and 60 months after surgery.

At baseline, 17% of the men reported having erections that were not firm enough for intercourse. That figure rose to 89% at 6 months following surgery and declined, thereafter, to 81% at 12 months, 75% at 24 months, and 71% at 60 months.

Discussing the study at a press briefing, Dr. Penson expressed surprise at the increase in potency between 24 and 60 months. “That's statistically significant, but it's also clinically meaningful,” he said.

He listed three possibilities for this finding:

▸ The first reason is that the study could have been inadequate. Some patients were lost to follow-up, and this may have skewed the results.

▸ The second reason is that perhaps there was a true late return of function. “That's a new idea,” Dr. Penson said. “Most urologists would say, if you're not potent by 2 years it's probably not going to get any better. Certainly that's what I've been telling my patients.”

▸ The last possibility is what Dr. Penson called the Viagra effect. Viagra became available in 1998, year 3 of the PCOS study.

Patients in the study were asked whether they tried Viagra (sildenafil), and if so, how much they thought it helped. About two-thirds of the men under age 60 at the time of surgery who tried Viagra said the drug helped somewhat or a lot. This percentage declined significantly among men over 60, however. For example, 66% of men aged 60–64 years said that Viagra didn't help at all.

The study also examined the effect of nerve-sparing surgery. As expected, bilateral nerve-sparing surgery proved to be significantly more effective at preserving potency than unilateral nerve-sparing surgery or no nerve sparing.

Bilateral nerve-sparing surgery helped younger men significantly more than older men. Among men aged 39–54 years at the time of the surgery, 71% reported erections firm enough for intercourse. But only 46% of the men aged 60–64 years and 18% of the men aged 65 and older reported that bilateral nerve-sparing surgery preserved their potency.

Dr. Penson disclosed a relationship with Pfizer Inc., maker of Viagra, as well as with several other pharmaceutical companies.

SAN ANTONIO — A large longitudinal study of men who underwent radical prostatectomy has shown a small but statistically significant increase in sexual potency between 2 and 5 years after radical prostatectomy, David F. Penson, M.D., reported at the annual meeting of the American Urological Association.

On the other hand, incontinence worsened between 2 and 5 years post surgery after improving between 6 months and 2 years, according to Dr. Penson of the University of Southern California, Los Angeles.

Part of the Prostate Cancer Outcomes Study (PCOS), the population-based, longitudinal study used tumor registries to identify all men with prostate cancer in three states—Connecticut, New Mexico, and Utah—and three metropolitan areas—Atlanta, Los Angeles, and Seattle.

Dr. Penson's study included 1,288 men with localized prostate cancer who underwent radical prostatectomy. The patients completed surveys at baseline and then again at 6, 12, 24, and 60 months after surgery.

At baseline, 17% of the men reported having erections that were not firm enough for intercourse. That figure rose to 89% at 6 months following surgery and declined, thereafter, to 81% at 12 months, 75% at 24 months, and 71% at 60 months.

Discussing the study at a press briefing, Dr. Penson expressed surprise at the increase in potency between 24 and 60 months. “That's statistically significant, but it's also clinically meaningful,” he said.

He listed three possibilities for this finding:

▸ The first reason is that the study could have been inadequate. Some patients were lost to follow-up, and this may have skewed the results.

▸ The second reason is that perhaps there was a true late return of function. “That's a new idea,” Dr. Penson said. “Most urologists would say, if you're not potent by 2 years it's probably not going to get any better. Certainly that's what I've been telling my patients.”

▸ The last possibility is what Dr. Penson called the Viagra effect. Viagra became available in 1998, year 3 of the PCOS study.

Patients in the study were asked whether they tried Viagra (sildenafil), and if so, how much they thought it helped. About two-thirds of the men under age 60 at the time of surgery who tried Viagra said the drug helped somewhat or a lot. This percentage declined significantly among men over 60, however. For example, 66% of men aged 60–64 years said that Viagra didn't help at all.

The study also examined the effect of nerve-sparing surgery. As expected, bilateral nerve-sparing surgery proved to be significantly more effective at preserving potency than unilateral nerve-sparing surgery or no nerve sparing.

Bilateral nerve-sparing surgery helped younger men significantly more than older men. Among men aged 39–54 years at the time of the surgery, 71% reported erections firm enough for intercourse. But only 46% of the men aged 60–64 years and 18% of the men aged 65 and older reported that bilateral nerve-sparing surgery preserved their potency.

Dr. Penson disclosed a relationship with Pfizer Inc., maker of Viagra, as well as with several other pharmaceutical companies.

SAN FRANCISCO — Studies show that about 70% of patients with heart failure also have coronary artery disease, and the decision on 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, he said.

“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,” he noted.

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.

Dr. O'Gara 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, such as the one that can be found on the Web site of the Society of Thoracic Surgeons (www.sts.org/sections/stsnationaldatabase/riskcalculator/

SAN FRANCISCO — Studies show that about 70% of patients with heart failure also have coronary artery disease, and the decision on 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, he said.

“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,” he noted.

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.

Dr. O'Gara 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, such as the one that can be found on the Web site of the Society of Thoracic Surgeons (www.sts.org/sections/stsnationaldatabase/riskcalculator/

SAN FRANCISCO — Studies show that about 70% of patients with heart failure also have coronary artery disease, and the decision on 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, he said.

“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,” he noted.

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.

Dr. O'Gara 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, such as the one that can be found on the Web site of the Society of Thoracic Surgeons (www.sts.org/sections/stsnationaldatabase/riskcalculator/