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BACKGROUND: Recent studies show Silent Myocardial Infarction (SMI) as a quite frequent event. However, regarding severe tertiary care patients that frequently present consequences of Coronary Artery Disease (CAD) and Left Ventricular Dysfunction (LVD), the occurrence of this manifestation is unexpected and its associated factors aren't clear in the literature. AIM: To compare clinical, laboratorial, ventricular and angiographic factors between silent and classical presentation of MI in patients with CAD and LVD. METHODS: Patients with multivessel CAD with over 70 % obstructive lesions and LVD with EF less than 35 % were evaluated for MASS VI trial and later included in the present study. The ventricular function and coronary assessment were measured by echocardiography and SYNTAX score, respectively. The population was stratified in a SMI group and Clinically Manifested Myocardial Infarction (CMMI) group based on MI presentation for a comparison of medical parameters. RESULTS: From 132 patients, 47 (35.6 %) were classified as SMI and 85 (64.4 %) as CMMI. No differences were observed between groups regarding age, sex, diabetes mellitus, SYNTAX score, or collateral circulation. Higher proportion of NYHA II classification, inferior wall MI and lower creatinine clearance were found in SMI group. After multivariate analysis, peripheral diabetic neuropathy (OR = 4.6 [1.1‒12.7] p = 0.032) and inferior wall MI (OR = 4.1 [1.5‒11.4] p = 0.007) were significantly associated with SMI. CONCLUSION: Peripheral diabetic neuropathy and inferior wall MI were associated with SMI presentation. Overall, associated factors tend to be similar comparing SMI and CMMI, but in the specific population of diabetic patients with chronic neuropathy a special care should be taken.

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BACKGROUND: Ischemia with the non-obstructive coronary artery (INOCA) is an ischemic heart disease that mostly includes coronary microvascular dysfunction and/or epicardial coronary vasospasm due to underlying coronary vascular dysfunction and can be seen more commonly in female patients. The systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio) is a new marker that predicts adverse clinical outcomes in coronary artery disease (CAD). OBJECTIVE: This study aims to investigate the relationship between INOCA and SII, a new marker associated with inflammation. METHODS: A total of 424 patients (212 patients with INOCA and 212 normal controls) were included in the study. Peripheral venous blood samples were received from the entire study population prior to coronary angiography to measure SII and other hematological parameters. In our study, the value of p<0.05' was considered statistically significant. RESULTS: The optimal cut-off value of SII for predicting INOCA was 153.8 with a sensitivity of 44.8% and a specificity of 78.77% (Area under the curve [AUC]: 0.651 [95% CI: 0.603-0.696, p=0.0265]). Their ROC curves were compared to assess whether SII had an additional predictive value over components. The AUC value of SII was found to be significantly higher than that of lymphocyte (AUC: 0.607 [95% CI: 0.559-0.654, p = 0.0273]), neutrophil (AUC: 0.559 [95%CI: 0.511-0.607, p=0.028]) and platelet (AUC: 0.590 [95% CI: 0.541-0.637, p = 0.0276]) in INOCA patients. CONCLUSIONS: A high SII level was found to be independently associated with the existence of INOCA. The SII value can be used as an indicator to add to the traditional expensive methods commonly used in INOCA prediction.

FUNDAMENTO: A isquemia com artéria coronária não obstrutiva (INOCA) é uma doença cardíaca isquêmica que inclui principalmente disfunção microvascular coronariana e/ou vasoespasmo coronariano epicárdico devido à disfunção vascular coronariana subjacente e pode ser observada mais comumente em pacientes do sexo feminino. O índice de inflamação imunológica sistêmica (SII, relação plaquetas × neutrófilos/linfócitos) é um novo marcador que prediz resultados clínicos adversos na doença arterial coronariana (DAC). OBJETIVO: Este estudo tem como objetivo investigar a relação entre INOCA e SII, um novo marcador associado à inflamação. MÉTODOS: Um total de 424 pacientes (212 pacientes com INOCA e 212 controles normais) foram incluídos no estudo. Amostras de sangue venoso periférico foram recebidas de toda a população do estudo antes da angiografia coronária para medir o SII e outros parâmetros hematológicos. Em nosso estudo o valor de p<0,05' foi considerado estatisticamente significativo. RESULTADOS: O valor de corte ideal do SII para prever o INOCA foi 153,8, com sensibilidade de 44,8% e especificidade de 78,77% (Área sob a curva [AUC]: 0,651 [IC 95%: 0,603­0,696, p=0,0265]). Suas curvas ROC foram comparadas para avaliar se o SII tinha um efeito preditivo adicional valor sobre os componentes. O valor da AUC do SII foi significativamente maior do que o do linfócito (AUC: 0,607 [IC 95%: 0,559­0,654, p = 0,0273]), neutrófilos (AUC: 0,559 [IC 95%: 0,511­0,607, p = 0,028]) e plaquetas (AUC: 0,590 [IC 95%: 0,541­0,637, p = 0,0276]) em pacientes INOCA. CONCLUSÕES: Verificou-se que um nível elevado de SII estava independentemente associado à existência de INOCA. O valor do SII pode ser usado como um indicador para adicionar aos métodos tradicionais e caros comumente usados na previsão do INOCA.

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OBJECTIVES: Transient ischemic dilatation (TID) in myocardial perfusion single photon emission computed tomography (SPECT) is considered a marker of poor prognosis. However, it has been suggested that some cases are due to apparent volumetric changes secondary to differences in heart rate (HR) at the time of acquisition. We assessed the correlation between transient dilatation and HR in low risk patients with no perfusion defects. METHODS: We retrospectively analyzed patients sent for 99mTc-MIBI SPECT using a 2-day protocol. We recorded the median HR during acquisition and the HR difference (HRD) between the rest and post-stress. We obtained the medium ventricular volume, end-diastolic volume (EDV), and end-systolic volume (ESV). We included patients in which TID using medium ventricular volume (TIDMV) was ≥1.2. TID was also calculated for the EDV and ESV (TIDEDV, TIDESV). We excluded patients with known coronary artery disease, perfusion defects, various ECG disorders, positive stress test, or ESV < 10 ml. RESULTS: From a total of 2006 patients, 63 (50 exercise, 13 dipyridamole) met the criteria for analysis (age 63.8 ±â€…9.7, 44 men). TIDMV was 1.29 ±â€…0.09 and HRD 9.8 beats per minute (BPM) (range -10 to 41). There was positive correlation between HRD and TIDMV ( r  = 0.51, P  < 0.001) and TIDEDV ( r  = 0.5, P  < 0.001), but not TIDESV ( r  = 0.23, P  = 0.07). Correlation was stronger when HRD was ≥10 BPM ( r  = 0.67, P  < 0.001). CONCLUSION: TID without perfusion defects should be interpreted with caution in the presence of HRD ≥ 10 BPM during post-stress acquisition.

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BACKGROUND: Chest pain is responsible for millions of visits to the emergency department (ED) annually. Cardiac ultrasound can detect ischemic changes, but varying accuracy estimates have been reported in previous studies. We synthetized the available evidence to yield more precise estimates of the accuracy of cardiac ultrasound for acute myocardial ischemia in patients with chest pain in the ED and to assess the effect of different clinical characteristics on test accuracy. METHODS: A systematic search for studies assessing the diagnostic accuracy of cardiac ultrasound for myocardial ischemia in the ED was conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Web of Science, two trial registries and supplementary methods, from inception to December 6th, 2022. Prospective cohort, cross-sectional, case-control studies and randomized controlled trials (RCTs) that included data on diagnostic accuracy were included. Risk of bias was assessed with the QUADAS-2 tool and a bivariate hierarchical model was used for meta-analysis with paired Forest and SROC plots used to present the results. Subgroup analyses was conducted on clinically relevant factors. RESULTS: Twenty-nine studies were included, with 5043 patients. The overall summary sensitivity was 79.3% (95%CI 69.0-86.8%) and specificity was 87.3% (95%CI 79.9-92.2%), with substantial heterogeneity. Subgroup analyses showed increased sensitivity in studies where ultrasound was conducted at ED admission and increased specificity in studies that excluded patients with previous heart disease, when the target condition was acute coronary syndrome, or when final chart review was used as the reference standard. There was very low certainty in the results based on serious risk of bias and indirectness in most studies. CONCLUSIONS: Cardiac ultrasound may have a potential role in the diagnostic pathway of myocardial ischemia in the ED; however, a pooled accuracy must be interpreted cautiously given substantial heterogeneity and that important patient and test characteristics affect its diagnostic performance. PROTOCOL REGISTRATION: PROSPERO (CRD42023392058).

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La evaluación de la perfusión miocárdica con SPECT combina una prueba de esfuerzo (ergometría o estrés farmacológico) junto a imágenes de perfusión con radioisótopos. Este estudio es útil para establecer el diagnóstico de enfermedad arterial coronaria, estratificar el riesgo de infarto y tomar decisiones terapéuticas. Un resultado normal aporta un alto valor predictivo negativo, es decir, una muy baja probabilidad de que el paciente presente eventos cardiovasculares. El hallazgo de signos de isquemia en la ergometría podría poner en jaque el valor predictivo negativo de una perfusión normal. En presencia de este resultado, el paso siguiente es evaluar los predictores de riesgo en la ergometría, el riesgo propio del paciente en función de los antecedentes clínicos y el puntaje cálcico coronario, cuando este se encuentra disponible. Ante la presencia concomitante de otros marcadores de riesgo se sugiere completar la evaluación con un estudio anatómico.El uso de nuevas tecnologías podría mejorar la precisión en la predicción de eventos. (AU)

Assessment of myocardial perfusion with SPECT combines a stress test (ergometry or pharmacological stress) with radioisotope perfusion imaging. This test is helpful to diagnose coronary artery disease, stratify the risk of heart attack, and make therapeutic decisions. A normal result provides a high negative predictive value; therefore, the probability of cardiovascular events is very low. Signs of ischemia on an ergometry could jeopardize the negative predictive value of normal perfusion. In this clinical setting, the next step is to evaluate the risk predictors in the stress test, the individual risk based on the clinical history, and the coronary calcium score when available. Given the simultaneous presence of other risk markers,completing the evaluation with an anatomical study is suggested. The use of new technologies could improve the accuracy of event prediction. (AU)

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BACKGROUND: Central Illustration : Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography ESBPRE: exaggerated systolic blood pressure response to exercise; HR: heart rate; SBP: systolic blood pressure. BACKGROUND: The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome. OBJECTIVE: To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE). METHODS: This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test. RESULTS: Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009). CONCLUSION: Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

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La isquemia miocárdica es un fenómeno secundario a la perfusión insuficiente del músculo cardíaco que en algunos casos puede ocurrir de forma aguda llevando a la necrosis celular y constituyendo el infarto agudo al miocardio (IAM). A pesar de que el diagnóstico de IAM es principalmente clínico, en ciertos casos en que no se sospeche de forma activa por presentar síntomas no típicos de isquemia miocárdica, el diagnóstico puede sugerirse por la Tomografía Computarizada (TC), que puede mostrar hallazgos sugerentes de IAM. A continuación, se comunica una serie de 4 casos clínicos con diagnóstico imagenológico incidental de IAM.

Myocardial ischemia is secondary to myocardial under perfusion. It can develop acutely leading to cell necrosis and myocardial infarction (AMI), or have a chronic course. Though the diagnosis of AMI is mainly clinical, in certain cases the symptoms may be atypical and the diagnosis can be suggested by images such as Computed Tomography (CT). Herein we report a series of 4 clinical cases with diagnosis of AMI following incidental CT imaging. There was an abdominal pain in 3 patients and a cervical pain in the remaining one. CT scan showed a hypodense myocardial image. The final diagnosis was confirmed by the appropriate laboratory and angiographic methods.

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BACKGROUND: Stress-induced myocardial ischemia seems not to be associated with cardiovascular events. However, its effects on myocardial tissue characteristics remain under debate. Thus, we sought to assess whether documented stress-induced ischemia is associated with changes in myocardial microstructure evaluated by magnetic resonance native T1 map and extracellular volume fraction (ECV). METHODS: This is a single-center, analysis of the previously published MASS V Trial. Multivessel patients with a formal indication for myocardial revascularization and with documented stress-induced ischemia were included in this study. Native T1 and ECV values evaluated by cardiac magnetic resonance imaging of ischemic and nonischemic myocardial segments at rest and after stress were compared. Myocardial ischemia was detected by either nuclear scintigraphy or stress magnetic cardiac resonance protocol. RESULTS: Between May 2012 and March 2014, 326 prospective patients were eligible for isolated CABG or PCI and 219 were included in the MASS V trial. All patients underwent resting cardiac magnetic resonance imaging. Of a total of 840 myocardial segments, 654 were nonischemic segments and 186 were ischemic segments. Native T1 and ECV values of ischemic segments were not significantly different from nonischemic segments, both at rest and after stress induction. In addition, native T1 and ECV values of myocardial segments supplied by vessels with obstructive lesions were similar to those supplied by nonobstructive ones. CONCLUSION AND RELEVANCE: In this study, cardiac magnetic resonance identified similar T1 mapping values between ischemic and nonischemic myocardial segments. This finding suggests integrity and stability of myocardial tissue in the presence of stress-induced ischemia.

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Ischemic heart disease continues to be the leading cause of death and disability worldwide. For the diagnosis of ischemic heart disease, some form of cardiac stress test involving exercise or pharmacological stimulation continues to play an important role, despite advances within modalities like computer tomography for the noninvasive detection and characterization of epicardial coronary lesions. Among noninvasive stress imaging tests, cardiac magnetic resonance (CMR) combines several capabilities that are highly relevant for the diagnosis of ischemic heart disease: assessment of wall motion abnormalities, myocardial perfusion imaging, and depiction of replacement and interstitial fibrosis markers by late gadolinium enhancement techniques and T1 mapping. On top of these qualities, CMR is also well tolerated and safe in most clinical scenarios, including in the presence of cardiovascular implantable devices, while in the presence of renal disease, gadolinium-based contrast should only be used according to guidelines. CMR also offers outstanding viability assessment and prognostication of cardiovascular events. The last 2019 European Society of Cardiology guidelines for chronic coronary syndromes has positioned stress CMR as a class I noninvasive imaging technique for the diagnosis of coronary artery disease in symptomatic patients. In the present review, we present the current state-of-the-art assessment of myocardial ischemia by stress perfusion CMR, highlighting its advantages and current shortcomings. We discuss the safety, clinical, and cost-effectiveness aspects of gadolinium-based CMR-perfusion imaging for ischemic heart disease assessment.

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Objective: Associating comorbidities and cardiac symptoms that alter myocardial mechanical function could help clinicians to correctly identify at-risk population. Methods: We conducted a functional open population cross-sectional study of patients referred to a positron emission computed tomography/computed tomography unit in Mexico City for evaluation of myocardial function, perfusion, and coronary circulation. Ischemia was defined as a sum difference score (SDS) > 2. Association between comorbidities and cardiac symptoms was tested using logistic regression models and trend analysis. We performed an interaction analysis to evaluate the addition of any accompanying symptoms to comorbid conditions on impairment of myocardial function. Results: One thousand two hundred and seventy-three patients were enrolled, 66.1% male, with a mean age of 62.4 (± 12.7) years, 360 (28.7%) with ischemia, 925 (72.7%) with at least one comorbidity, and 676 (53.1%) had at least one associated cardiac symptom. Patients without ischemia, type 2 diabetes, arterial hypertension, and adverse cardiac symptoms were associated with adverse function, perfusion, and coronary flow parameters. We observed a trend of a cumulative number of comorbidities and cardiac symptoms with increased ischemia and decreased coronary flow. Only in decreased LVEF, we demonstrated an interaction effect between increased comorbidities and adverse symptoms. Conclusions: The high burden of comorbidities and symptoms in our population alter myocardial function regardless of the level of ischemia.

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INTRODUCCIÓN En los últimos años, se ha desarrollado la aplicación de una nueva tecnología: SPECT/TC digital, con detectores digitales de conversión directa con tecnología CZT (cadmio zinc teluro) que provee a los equipos, de alta resolución y contraste, con tiempos de estudio significativamente más cortos, ampliando de esta forma el campo de aplicación e incrementando el rendimiento de los equipos. En las "cámaras CZT", el cristal convencional de sodio/yodo (NaI) utilizado para la detección de rayos gamma ha sido reemplazado por un cristal de cadmio-zinc-teluro (CZT). Este cristal transforma directamente la señal inducida por los rayos gamma en impulsos eléctricos sin necesidad de fotodetectores. La interacción de un fotón gamma de 140 keV en los detectores CZT produce aproximadamente 30.000 electrones, 20 veces más que los producidos en un cristal de NaI convencional, mejorando la resolución energética por un factor de 2 en comparación con las cámaras Anger convencionales. La aportación más relevante de esta nueva tecnología respecto a la convencional sería la calidad de imagen, determinada por 3 factores: resolución energética, resolución espacial y sensibilidad. En el estudio de la perfusión coronaria, usando estas tecnologías, se ha desarrollado la imagen multimodal que surge de la necesidad de integrar la información anatómica (que define el árbol coronario morfológicamente) con la funcional (que refleja la afectación tisular de dicha enfermedad) con el fin de evaluar correctamente a los pacientes afectos de cardiopatía isquémica. Esta imagen multimodal se realiza de forma directa mediante equipos híbridos como el SPECT/TC que integran dos tecnologías en un mismo equipo permitiendo una mejor estratificación del riesgo del paciente. La fusión mediante el software de las imágenes de la perfusión tomadas con el SPECT con la anatómica de la TC ofrece información diagnóstica superior a la identificación aislada de la lesión y, además, esta información dual se puede obtener con procedimientos no invasivos y de forma ambulatoria. Recientemente la incorporación de receptores CZT en equipos no dedicados específicamente a la imagen cardiaca (equipos multipropósito o total body), han permitido la expansión del uso a la evaluación de otras zonas corporales donde los equipos tradicionales de SPECT-TC ya se estaban empleando. OBJETIVOS: El objetivo de este informe es describir la eficacia diagnóstica y la seguridad SPECT/TC con detectores digitales de conversión directa con tecnología CZT (cadmio, zinc, teluro) frente a equipos semejantes dotados de sensores convencionales, en la evaluación de la perfusión miocárdica en pacientes con cardiopatía isquémica. Como objetivo secundario se describirá la utilización de estos equipos en otras patologías y usos clínicos, en los que exista evidencia disponible. MÉTODOS: Tras la definición de las preguntas de investigación se definieron varias estrategias de búsqueda bibliográfica para diferentes bases de datos (MEDLINE, EMBASE, CENTRAL y Cochrane library). Las búsquedas se orientaron principalmente a conocer la efectividad y seguridad de acuerdo con las preguntas formuladas. Las búsquedas y la selección de la bibliografía se realizaron atendiendo a criterios diferenciados para los dos ámbitos de uso de la tecnología: la aplicación al estudio de la perfusión cardiaca y el uso en otras áreas. Para el primer caso se seleccionaron estudios que aportasen la mayor certeza en sus conclusiones, para la segunda parte se hizo una revisión panorámica con el objeto de identificar la mayor cantidad de ámbitos de utilización. La selección, depuración y síntesis de la información se realizó por duplicado y en caso de duda esta fue resulta por consenso. Para la evaluación de la calidad se utilizó la herramienta AMSTAR-2 para revisiones y seleccionada para estudios observacionales se empleó la herramienta Robins-I. La síntesis de la evidencia se realizó utilizando la metodología GRADE con la herramienta GRADE-Pro. Los resultados y las conclusiones fueron consensuados por el conjunto de los autores. RESULTADOS: Los resultados se estructuraron en dos partes: resultados de eficacia y seguridad de SPECT/TC CZT en la evaluación de la perfusión cardiaca y descripción de otras aplicaciones. EFICACIA Y SEGURIDAD DE SPECT/TC CZT PARA EL ANÁLISIS DE LA PERFUSIÓN CARDIACA. Pregunta 1: Efectividad en pacientes con sospecha de isquemia coronaria. Tras la búsqueda bibliográfica fue posible identificar una revisión sistemática cuyo objetivo era comparar el rendimiento diagnóstico entre SPECT-CZT y SPECT-convencional en pacientes con enfermedad coronaria confirmada mediante angiografía. Esta revisión fue calificada de baja calidad según criterios AMSTAR-II. La comparación de la eficacia diagnóstica entre ambas técnicas se realizó de forma indirecta pues los autores de la revisión no pudieron identificar trabajos que comparasen directamente ambas técnicas sobre una muestra de pacientes de una misma población. La revisión se centró en el análisis de la eficacia diagnóstica, medida en términos de sensibilidad y especificidad: Así, la sensibilidad estimada es de 85% [IC95% 79%-89%] para SPECT-Convencional frente a 89% [IC95% 86%-91%] para SPECT-CZT y la especificidad es 66% [IC95% 56%-74%] y 69% [IC95% 61%-75%]. El análisis de las curvas ROC muestra un área bajo la curva ligeramente mayor para SPECT-CZT área=0,89 [IC95% 0,86-0,92], con regiones de confianza y predicción bastante restringidas, en comparación con SPECT-C área=0,83 [IC95% 0,80-0,86]. (Test de hipótesis de la comparación p=0,03). Pregunta 2: Seguridad en pacientes con sospecha de isquemia coronaria. Como en otros estudios diagnósticos de imagen híbrida los principales riesgos están asociados con la potencial exposición a radiación. Se identificó un estudio observacional con grupo control apareado por edad, sexo e índice de masa corporal. En él se incluyeron pacientes remitidos a una sola institución para la evaluación de una posible enfermedad coronaria mediante SPECT, se cuantificó en cada uno de los pacientes la dosis total de radiación recibida en todo el proceso diagnóstico y de tratamiento hasta 90 días después de la indicación de la prueba, incluyendo la recibida en el SPECT, las angiografías, cateterismos y la intervención coronaria percutánea cuando esta fue realizada. Tanto el grupo intervención (SPECT-CZT) como los controles (SPECT-convencional) parecieron seguir la misma rutina diagnóstica y terapéutica según los hallazgos y necesidades indicadas por los profesionales responsables. Se evaluó el riesgo de sesgo de este trabajo mediante la herramienta Robins-I y fue calificado como de riesgo serio. Es preciso considerar, además, que esta evidencia es indirecta pues los pacientes no fueron evaluados con equipos híbridos, sino con equipos de SPECT no dotados de TC. El principal resultado mostrado es la diferencia de dosis recibida que entre los pacientes incluidos en el grupo expuesto a SPECT-CZT y los incluidos en el grupo de comparación fue estimada en -3,1 mSv [IC95% -4,32; -1,87]. OTRAS APLICACIONES La búsqueda permitió identificar inicialmente 35 referencias susceptibles de describir aplicaciones clínicas presentes o de pronta incorporación de la tecnología objeto del presente informe. Tras la selección y depuración de los trabajos identificados finalmente sólo 6 originales aportaron información útil. La aplicación no relacionada con la perfusión coronaria descrita con mayor frecuencia es el estudio de la perfusión vascular cerebral, posiblemente debido a la mejora de la resolución y la rapidez del análisis que han aportado los sensores de CZT. También se han descrito la utilidad para la detección y seguimiento de lesiones sólidas de origen tumoral o sospechosas de serlo, especialmente en lesiones de mama, sistema linfático y óseas. Finalmente, también se ha comunicado el empleo de los dispositivos objeto del informe en el análisis y cuantificación de la fracción de eyección del ventrículo izquierdo. CONCLUSIONES: Actualmente, el uso de CZT supone la actualización de una tecnología ya consolidada. La evidencia identificada para evaluar el beneficio del SPECT-TC CZT frente a SPECT-TC, aunque de mala calidad y siendo indirecta permite concluir que podría ser más eficaz en el estudio de la enfermedad isquémica coronaria. La dosis de radiación recibida en los pacientes que se les realiza SPECT/TC CZT parece ser menor respecto a los que se les realiza SPECT/ TC convencional, si bien, la calidad de la evidencia se ha considerado muy baja esencialmente, por el riesgo de sesgo y ser indirecta. La utilización de esta tecnología para otras indicaciones diferentes de la cardiaca está empezando a definirse, en el momento actual la descrita con mayor frecuencia podría ser el estudio de la perfusión vascular cerebral y el estudio de lesiones sólidas malignas o sospechosas de malignidad.

INTRODUCTION In recent years, the application of a new technology has been developed: digital SPECT/CT, with direct conversion digital detectors with CZT (cadmium zinc telluride) technology that provides equipment with high resolution and contrast with significantly shorter study times, expanding the field of application and increasing the performance of the equipment. In "CZT cameras", the conventional sodium/iodine (NaI) crystal used for gamma ray detection has been obtained by a cadmium-zinc-telluride (CZT) crystal. This crystal directly transforms the signal induced by gamma rays into electrical impulses without needing photodetectors. The interaction of a 140 keV gamma photon in CZT detectors produces approximately 30,000 electrons, 20 times more than those produced in a conventional NaI crystal, improving energy resolution by a factor of 2 compared to conventional Anger cameras. The most relevant contribution of this new technology compared to conventional technology would be image quality, determined by 3 factors: energy resolution, spatial resolution and sensitivity. In the study of coronary perfusion, using these technologies, multimodal imaging has been developed; it arises from the need to integrate anatomical information (which defines the coronary tree morphologically) with functional information (which reflects the tissue involvement of said disease), in order to correctly evaluate patients with ischemic heart disease. This multimodal image is performed directly using hybrid equipment such as SPECT/CT that integrates two technologies in the same equipment, achieving better patient risk stratification. The fusion, obtained by software, of the perfusion images taken with SPECT with the anatomical one of the CT offers diagnostic information superior to the isolated identification of the lesion and, furthermore, this dual information can be obtained with non-invasive procedures and on an outpatient basis. It must be considered that, although the severity of coronary ischemia is related to the degree of stenosis, this relationship is not always linear. In addition to the degree of obstruction, various factors establish whether a given stenosis induces a myocardial perfusion defect: On the one hand, the existence of collateral circulation or arterial vasospasm can be highlighted and, on the other, a non-significant atherosclerotic plaque can become destabilized and cause a severe or even total arterial obstruction. Furthermore, the phenomenon of «ischemic preconditioning¼, understood. as a phenomenon of endogenous protection by which the myocardium better tolerates a potentially lethal insult when it has previously received sublethal insults, could play a role in the discrepancy between anatomical alterations and functional. For all of the above, to guide revascularization strategies, an evaluation of the functional relevance of coronary stenosis seems useful. Recently, the incorporation of CZT receptors in equipment not specifically dedicated to cardiac imaging (multipurpose or "total body" equipment) has allowed the expansion of its use to the evaluation of other body areas where traditional SPECT-CT equipment was already being used. AIMS: The objective of this report is to describe the diagnostic efficacy and safety of SPECT/CT with direct conversion digital detectors with CZT technology (cadmium, zinc, tellurium) compared to similar equipment equipped with conventional sensors, in the evaluation of myocardial perfusion in patients with ischemic heart disease. As a secondary objective, the use of this equipment in other pathologies and clinical use, in which there is available evidence, will be described. METHODS: After defining the research questions, several bibliographic search strategies were defined for different databases (MEDLINE, EMBASE, CENTRAL and Cochrane library). The searches were mainly aimed at knowing the effectiveness and safety according to the questions asked and the selection of the bibliography were carried out according to different criteria for the two areas of use of the technology: the application to the study of cardiac perfusion and the use in other areas. For the first case, studies that provided the greatest certainty in based on their conclusions were selected; for the second part, a panoramic review was made in order to identify the greatest number of areas of use. The selection, purification and synthesis of the information was carried out by two members of the group and in case of doubt it was solve by consensus. For quality assessment, the AMSTAR-2 tool was used for systematic reviews and the Robins-I tool was used for observational studies. Evidence synthesis was performed using the GRADE methodology with the GRADE-Pro tool. The results and key points were agreed upon by all the authors RESULTS The results were structured in two parts: efficacy and safety results of SPECT/CT CZT in the evaluation of cardiac perfusion and description of other applications. EFFICACY AND SAFETY OF SPECT/CT CZT FOR THE ANALYSIS OF CARDIAC PERFUSION. Question 1: Effectiveness in patients with suspected coronary ischemia. After the literature search, it was possible to identify a systematic review whose objective was to compare the diagnostic performance between SPECT-CZT and SPECT-conventional in patients with coronary artery disease confirmed by angiography. This review was rated as low quality according to AMSTAR-II criteria. The comparison of the diagnostic efficacy between both techniques was performed indirectly, since the authors of the review were unable to identify studies that directly compared both techniques on a sample of patients from the same population. The review focused on the analysis of diagnostic efficacy, measured in terms of sensitivity and specificity: Thus, the estimated sensitivity is 85% [95% CI 79%-89%] for SPECT-Conventional compared to 89% [95% CI 86 %-91%] for SPECT-CZT and the specificity is 66% [95% CI 56%-74%] and 69% [95% CI 61%-75%]. ROC curve analysis shows a slightly larger area under the curve for SPECT-CZT area=0.89 [95% CI 0.86-0.92], with fairly restricted confidence and prediction regions, compared to SPECT-C area=0.83 [CI95% 0.80-0.86]. (Comparison hypothesis test p=0.03). Question 2: Safety in patients with suspected coronary ischemia. As in other diagnostic hybrid imaging studies, the main risks are associated with potential exposure to radiation. An observational study with a control group matched for age, sex and body mass index was identified. It included patients referred to a single institution for the evaluation of a possible coronary artery disease by SPECT, the total dose of radiation received in each of the patients was quantified in the entire diagnostic and treatment process up to 90 days after the indication, including that received in the SPECT, the angiographies, catheterizations and the percutaneous coronary intervention when it was performed. Both, the intervention group (SPECT-CZT) and the control group (SPECTconventional) seemed to follow the same diagnostic and therapeutic routine according to findings and needs indicated by the responsible professionals. The risk of bias of this study was assessed using the Robins-I tool and was classified as serious risk. It should also be considered that this evidence is indirect, since the patients were not evaluated with hybrid equipment, but rather with SPECT equipment not equipped with CT. The main result shown is the difference in dose received between the patients included in the group exposed to SPECT-CZT and those included in the comparison group, estimated at -3.1 mSv [95% CI -4.32; -1.87]. OTHER APPS The search initially allowed the identification of 35 references likely to describe present clinical applications, or closely to be incorporated, of the technology that is the subject of this report. After the selection and filtering of the works finally identified, only 6 originals provided useful information. The most frequently described non-coronary perfusion application is the study of cerebral vascular perfusion, possibly due to the improved resolution and speed of analysis that CZT sensors have provided. Its usefulness for the detection and monitoring of solid lesions of tumor origin or suspected to be so, especially in breast, lymphatic system and bone lesions, has also been described. Finally, the use of the devices object of the report in the analysis and quantification of the ejection fraction of the left ventricle has also been reported. FINDINGS: Currently the use of CZT supposes the updating of an already consolidated technology. The evidence identified to evaluate the benefit of SPECT-CT CZT versus SPECT-CT, although of poor quality and being indirect, allows us to conclude that it could be more effective in the study of ischemic coronary disease. The radiation dose received in patients who undergo SPECT/CT CZT seems to be lower compared to those who undergo conventional SPECT/ CT, although the quality of the evidence has been considered very low, essentially due to the risk of bias and being indirect. The use of this technology for indications other than cardiac is beginning to be defined. Currently, the most frequently described could be the study of cerebral vascular perfusion and the study of solid malignant or suspected malignant lesions.

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BACKGROUND: Coronary arteries tend to be more tortuous than other arteries and follow the repeated flexion and relaxation movements that occur during the cardiac cycle. Coronary tortuosity (CorT) leads to changes in coronary flow with a reduction in distal perfusion pressure, which could cause myocardial ischemia. OBJECTIVE: To assess the association between CorT and myocardial ischemia. METHODS: Between January 2015 and December 2017, 57 patients with angina and nonobstructive coronary artery disease detected by invasive coronary angiography (ICA) were retrospectively enrolled. Angiographic variables were analyzed to assess the presence and degree of tortuosity and correlated with their respective vascular territories on stress myocardial perfusion imaging (MPI). CorT was defined as coronary arteries with three or more bend angles ≤90°, measured during diastole. Statistical significance was determined at the 5% level. RESULTS: A total of 17 men and 40 women were enrolled (mean age 58.3 years). CorT was observed in 16 patients (28%) and in 24 of 171 arteries. There was a significant association between CorT and ischemia when analyzed per artery (p<0.0001). The angiographic factor most associated with ischemia was the number of bend angles in an epicardial artery measured at systole (p=0.021). CONCLUSION: This study showed an association of CorT and myocardial ischemia in patients with unobstructed coronary arteries and angina. An increased number of coronary bend angles measured by angiography during systole was related to ischemia.

FUNDAMENTO: As artérias coronárias tendem a ser mais tortuosas que outras artérias e acompanham os movimentos repetidos de flexão e relaxamento que ocorrem durante o ciclo cardíaco. A Tortuosidade das artérias Coronárias (TCor) causa alterações no fluxo coronariano, com uma redução na pressão de perfusão distal, o que pode levar à isquemia miocárdica. OBJETIVO: Avaliar a associação entre TCor e isquemia miocárdica. MÉTODOS: Entre janeiro de 2015 e dezembro de 2017, 57 pacientes com angina e doença arterial coronariana não obstrutiva pela angiografia coronária invasiva (ACI) foram incluídos retrospectivamente. Variáveis angiográficas foram analisadas para avaliar a presença e grau de tortuosidade e correlacionadas com seus respectivos territórios vasculares na cintilografia de perfusão miocárdica com estresse. A TCor foi definida como artérias coronárias com três ou mais curvaturas com ângulos ≤ 90o, medidos durante diástole. Um nível de 5% foi estabelecido como estatisticamente significativo. Um nível de 5% foi definido como estatisticamente significativo. RESULTADOS: Um total de 17 homens e 40 mulheres foram incluídos (idade média de 58,3 anos). A TCor foi observada em 16 pacientes (28%) e em 24 das 171 artérias. Observou-se uma associação significativa entre TCor e isquemia na análise por artéria (p<0,0001). O fator angiográfico mais associado com isquemia foi o número de curvaturas em uma artéria epicárdica medido na sístole (p=0,021). CONCLUSÃO: Este estudo mostrou uma associação da TCor com isquemia miocárdica em pacientes com artérias coronárias não obstruídas e angina. Observou-se uma relação entre número aumentado de curvaturas na artéria coronária medido por angiografia durante sístole e isquemia.

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BACKGROUND: There is limited data on the prognostic value of stress cardiac magnetic resonance (CMR) in older adults. OBJECTIVE: To determine the prognostic value of adenosine stress CMR in older individuals with known or suspected coronary artery disease (CAD). METHODS: Between 2010 and 2015, consecutive patients aged 65 years or older referred for adenosine stress CMR were followed for the occurrence of severe cardiac events (cardiac death and nonfatal myocardial infarction) and major adverse cardiovascular events (MACE) that also included hospitalization for heart failure and ischemic stroke. Univariate and multivariate analyses were performed to determine the prognostic value of myocardial ischemia, with p-value <0.05 considered statistically significant. RESULTS: After a mean follow-up period of 50.4 months in 324 patients (48% male, 73±7 years), 21 severe cardiac events and 52 MACE occurred. Patients with myocardial ischemia (n=99) had significantly higher rates of severe cardiac events (HR 5.25 [95% CI 2.11-13.04], p<0.001) and MACE (HR 3.01 [95% CI 1.75-5.20], p<0.001) than those without ischemia. Multivariable analysis determined ischemia as an independent predictor of severe cardiac events (HR 3.14 [95% CI 1.22-8.07], p=0.02) and MACE (HR 1.91 [95%CI 1.02-3.59], p=0.04). Ischemia provided an incremental prognostic value over clinical factors and left ventricular ejection fraction for predicting severe cardiac events and MACE (p<0.01 for both). No severe adverse events occurred during or immediately after CMR examinations. CONCLUSION: Adenosine stress CMR is safe and has prognostic value in older adults with known or suspected CAD.

FUNDAMENTO: Há dados limitados sobre o valor prognóstico da ressonância magnética cardíaca (RMC) em estresse em pacientes idosos. OBJETIVO: Determinar o valor prognóstico da RMC em estresse com adenosina em idosos com doença arterial coronariana (DAC) conhecida ou suspeita. MÉTODOS: Entre 2010 e 2015, pacientes consecutivos com 65 anos ou mais encaminhados para RMC em estresse com adenosina foram acompanhados para a ocorrência de eventos cardíacos graves (morte cardíaca e infarto do miocárdio não-fatal) e eventos cardiovasculares adversos maiores (ECAM) que também incluíram hospitalização por insuficiência cardíaca e acidente vascular cerebral isquêmico. As análises univariadas e multivariadas foram realizadas para determinar o valor prognóstico da isquemia miocárdica, com valor de p <0,05 considerado estatisticamente significante. RESULTADOS: Após um período médio de seguimento de 50,4 meses em 324 pacientes (48% do sexo masculino, 73±7 anos), ocorreram 21 eventos cardíacos graves e 52 ECAM. Pacientes com isquemia miocárdica (n=99) apresentaram taxas significantemente maiores de eventos cardíacos graves (HR 5,25 [IC 95% 2,11-13,04], p<0,001) e ECAM (HR 3,01 [IC 95% 1,75-5,20], p<0,001) do que aqueles sem isquemia. A análise multivariada determinou a isquemia como preditor independente de eventos cardíacos graves (HR 3,14 [IC 95% 1,22-8,07], p=0,02) e ECAM (HR 1,91 [IC 95% 1,02-3,59], p=0,04). A isquemia forneceu um valor prognóstico incremental sobre fatores clínicos e fração de ejeção do ventrículo esquerdo para predizer eventos cardíacos graves e ECAM (p<0,01 para ambos). Nenhum evento adverso grave ocorreu durante ou imediatamente após os exames de RMC. CONCLUSÃO: A RMC em estresse com adenosina é segura e demonstra valor prognóstico em idosos com DAC conhecida ou suspeita.

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Background: Echocardiographic predictors for new onset heart failure in patients with ischemic heart disease with reduced left ventricular ejection fraction (HFrEF) or with preserved left ventricular ejection fraction (HFpEF) in Ethiopian and Sub-Saharan African is not well-known.Methods: Two hundred twenty-eight patients with ischemic heart disease were retrospectively recruited and followed. Analysis on baseline clinical and echocardiographic characteristics of patients, and risk factors for new onset HFpEF and new onset HFrEF were done. The exclusion criteria were known heart failure at baseline and those who did not have echocardiography data.Results: During the follow up period, heart failure developed in 62.2% (61/98) of ischemic heart disease patients with preserved left ventricular ejection fraction and in 70.1% (92/130) of ischemic heart disease patients with reduced left ventricular ejection fraction. We did not find significant difference between HFrEF and HFpEF in time to new onset heart failure. Systolic blood pressure, diastolic blood pressure, diabetes, left atrium and diastolic left ventricular dimension had significant association with new onset HFrEF on univariate regression analysis. Whereas new onset HFpEF was significantly associated with age, sex, presence of hypertension, Systolic blood pressure and diastolic left ventricular dimension. On cox regression analysis diastolic left ventricular dimension was associated with both new onset HFpEF and HFrEF. Age, diabetes, and dimension of left atrium were also associated with HFrEF.Conclusion: This cohort study in ischemic heart disease patients suggests a key role for the diastolic left ventricular dimension, left atrium size, diabetes, sex and age as predictors of new onset HFrEF and HFpEF. Strategies directed to prevention and early treatment of diabetes, dilatation of left ventricle and left atrium may prevent a considerable proportion of HFrEF or HFpEF.

Antecedentes: Los predictores ecocardiográficos de nuevos eventos de insuficiencia cardiaca en pacientes con cardiopatía isquémica con fracción de eyección ventricular preservada (HFpEF) o con fracción de eyección ventricular reducida (HFrEF) no son bien conocidos en la Africa etíope y subsahariana.Métodos: Doscientos veintiocho pacientes con cardiopatía isquémica fueron reclutados y seguidos retrospectivamente. Se realizaron análisis sobre las características clínicas y ecocardiográficas basales de los pacientes, así como los factores de riesgo para un nuevo evento de HFpEF y un nuevo evento de HFrEF. Los criterios de exclusión fueron insuficiencia cardíaca conocida al inicio del estudio y aquellos que no tenían datos de ecocardiografía.Resultados: Durante el período de seguimiento, la insuficiencia cardíaca se desarrolló en el 62,2% (61/98) de pacientes con cardiopatía isquémica con fracción de eyección ventricular izquierda preservada y en el 70,1% (92/130) de pacientes con cardiopatía isquémica con fracción de eyección ventricular izquierda reducida. No encontramos diferencias significativas entre HFrEF y HFpEF en el tiempo hasta la nueva aparición de insuficiencia cardíaca. La presión arterial sistólica, la presión arterial diastólica, la diabetes y las dimensiones de la aurícula iquierda y del ventrículo izquierdo en diástole tuvieron una asociación significativa con nuevos eventos de HFrEF en el análisis de regresión univariada. Mientras que un nuevo evento de HFpEF se asoció significativamente con la edad, el sexo, la presencia de hipertensión, la presión arterial sistólica y la dimensión ventricular izquierda diastólica. En el análisis de regresión de cox, la dimensión ventricular izquierda diastólica se asoció con HFpEF de nuevo inicio y HFrEF. La edad, la diabetes y la dimensión de la aurícula izquierda también se asociaron con HFrEF. Conclusión: Este estudio de cohorte en pacientes con cardiopatía isquémica sugiere un papel clave para la dimensión ventricular izquierda diastólica, el tamaño de la aurícula izquierda, la diabetes, el sexo y la edad como predictores de un nuevo evento de HFrEF y HFpEF. Las estrategias dirigidas a la prevención y el tratamiento temprano de la diabetes, la dilatación del ventrículo izquierdo y la aurícula izquierda pueden prevenir una proporción considerable de HFrEF o HFpEF.

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Fundamentos: O papel da cintilografia de perfusão miocárdica em pacientes assintomáticos permanece restrito a situações clínicas muito específicas, muitas delas abordadas nos Critérios de Uso Apropriado (AUC) de Cintilografia de Perfusão Miocárdica. Objetivo: Realizar uma análise crítica da aplicação desses critérios nas indicações de exames realizados em pacientes assintomáticos do Instituto Dante Pazzanese de Cardiologia, cuja população é notadamente de alto risco cardiovascular. Métodos: Foram selecionados pacientes assintomáticos que realizaram cintilografia de perfusão miocárdica para pesquisa de isquemia. As indicações dos exames foram classificadas em apropriadas, inapropriadas ou incertas. Hipocaptação fixa, hipocaptação transitória ou dilatação isquêmica transitória foram consideradas exames alterados. Na análise estatística, buscou-se avaliar a correlação entre o grau de recomendação das indicações e a presença de exames alterados. Resultados: A partir de uma seleção inicial de 2.999 prontuários, 490 foram considerados assintomáticos e incluídos conforme critérios de inclusão estabelecidos previamente. Apenas 9,8% das indicações foram inapropriadas, enquanto que 61,4% foram apropriadas, e 28,8% foram incertas. A hipocaptação fixa do radiofármaco ocorreu em 43,5% dos casos e a hipocaptação transitória, em 16,1%. Solicitar o exame de maneira apropriada ou incerta foi fator preditor de exame com resultado alterado nesta população. Conclusão: O uso dos critérios de uso apropriado da cintilografia de perfusão miocárdica mostrou-se eficaz em predizer exames alterados em uma população assintomática de alto risco cardiovascular, especialmente no grupo de pacientes com indicação incerta, o que pode significar que algumas das indicações consideradas incertas talvez sejam apropriadas para uma população de alto risco cardiovascular. (AU)

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