Volume 44, Number 4
July 2014
Letter From the Editors
F
ollowing its introduction into routine nuclear cardiology in the mid-1970, myocardial perfusion imaging (MPI) witnessed great growth and popularity for 3 decades. Starting with thallium-201 planar imaging and progressing to SPECT imaging with Tc-99m sestamibi, MPI has added a powerful imaging tool for detecting both the presence and extent of coronary artery disease. As our knowledge increased and technologic advances flourished, it became possible to obtain additional information concerning risk assessment and prognosis. From 2000-2006, the use of MPI increased by 41%.1 However, for a variety of reasons, this trend has reversed with a 51% decline from 2006-2011. Several reasons have been cited to account for this decline. These include increased usage of other imaging examinations such as coronary CT angiography and stress echocardiography. Other factors including incorporation of appropriate use criteria, for example, diminishing referral for cardiac clearance of low-risk patients for noncardiac surgery, such as cataract removal, need for precertification, and a growing concern about patient radiation exposure have clearly played a role, as well. Finally and importantly, cardiologists performing myocardial perfusion studies in their private offices appear to have less incentive because of issues associated with reimbursement. Interestingly, there has also been a significant temporal change in the frequency of abnormal single-photon emission CT-MPI studies. From 1991, 40.9% of study findings were abnormal as compared with only 8.7% in 2009. More specifically, studies reflecting ischemia declined from 20.6%4.9% during the same period.2 The authors attribute this to a number of reasons including a reduction in risk factors such as a decline in smoking, family history of premature coronary artery disease, resting blood pressure measurements, cholesterol levels, and transfat ingestion amongst Americans. As pointed out by Dr Mark Travin3 in his guest editorial, advances in instrumentation, computer processing, and
http://dx.doi.org/10.1053/j.semnuclmed.2014.05.001 0001-2998/& 2014 Elsevier Inc. All rights reserved.
interpretive skills that have occurred in the past decade now allow us to better explore quantitative flow techniques such as coronary flow reserve and absolute coronary blood flow. An important new addition to our nuclear cardiology armamentarium is autonomic imaging with iodine 123 metaiodobenzylguanidine (123I-mIBG), which, as Dr Travin4 shows, promises to become part of routine heart failure imaging to assist in planning implantable defibrillators. Assessment of left ventricular mechanical synchronology is another new area that will, hopefully, support what now appears to be a renewed interest in radionuclide cardiac imaging.5 Dr Travin has assembled a superb group of colleagues to contribute to this most informative first part of a 2-issue Seminar on Nuclear Cardiology. We look forward to an equally impressive Part 2. Leonard M. Freeman, MD M. Donald Blaufox, MD, PhD
References 1. McNulty EJ, Hung Y-Y, Almers LM, et al: Population trends from 20002011 in nuclear myocardial perfusion imaging use. J Am Med Assoc 2014;311:1248-1249 [letter to the editor] 2. Rozanski A, Gransar H, Hayes SW, et al: Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing. J Am Coll Cardiol 2013;61:1054-1065 3. Travin MI: Letter from the Guest Editor: Update in Cardiovascular Nuclear Medicine. Semin Nucl Med 2014;44:230-231 4. Travin MI: Cardiac Radionuclide Imaging to Assess Patients With Heart Failure. Semin Nucl Med 2014;44:294-313 5. Soman P, Chen J: Left Ventricular Dyssynchrony Assessment Using Myocardial Single-Photon Emission CT. Semin Nucl Med 2014;44:314-319
229
July 2014
Letter From the Editors
F
ollowing its introduction into routine nuclear cardiology in the mid-1970, myocardial perfusion imaging (MPI) witnessed great growth and popularity for 3 decades. Starting with thallium-201 planar imaging and progressing to SPECT imaging with Tc-99m sestamibi, MPI has added a powerful imaging tool for detecting both the presence and extent of coronary artery disease. As our knowledge increased and technologic advances flourished, it became possible to obtain additional information concerning risk assessment and prognosis. From 2000-2006, the use of MPI increased by 41%.1 However, for a variety of reasons, this trend has reversed with a 51% decline from 2006-2011. Several reasons have been cited to account for this decline. These include increased usage of other imaging examinations such as coronary CT angiography and stress echocardiography. Other factors including incorporation of appropriate use criteria, for example, diminishing referral for cardiac clearance of low-risk patients for noncardiac surgery, such as cataract removal, need for precertification, and a growing concern about patient radiation exposure have clearly played a role, as well. Finally and importantly, cardiologists performing myocardial perfusion studies in their private offices appear to have less incentive because of issues associated with reimbursement. Interestingly, there has also been a significant temporal change in the frequency of abnormal single-photon emission CT-MPI studies. From 1991, 40.9% of study findings were abnormal as compared with only 8.7% in 2009. More specifically, studies reflecting ischemia declined from 20.6%4.9% during the same period.2 The authors attribute this to a number of reasons including a reduction in risk factors such as a decline in smoking, family history of premature coronary artery disease, resting blood pressure measurements, cholesterol levels, and transfat ingestion amongst Americans. As pointed out by Dr Mark Travin3 in his guest editorial, advances in instrumentation, computer processing, and
http://dx.doi.org/10.1053/j.semnuclmed.2014.05.001 0001-2998/& 2014 Elsevier Inc. All rights reserved.
interpretive skills that have occurred in the past decade now allow us to better explore quantitative flow techniques such as coronary flow reserve and absolute coronary blood flow. An important new addition to our nuclear cardiology armamentarium is autonomic imaging with iodine 123 metaiodobenzylguanidine (123I-mIBG), which, as Dr Travin4 shows, promises to become part of routine heart failure imaging to assist in planning implantable defibrillators. Assessment of left ventricular mechanical synchronology is another new area that will, hopefully, support what now appears to be a renewed interest in radionuclide cardiac imaging.5 Dr Travin has assembled a superb group of colleagues to contribute to this most informative first part of a 2-issue Seminar on Nuclear Cardiology. We look forward to an equally impressive Part 2. Leonard M. Freeman, MD M. Donald Blaufox, MD, PhD
References 1. McNulty EJ, Hung Y-Y, Almers LM, et al: Population trends from 20002011 in nuclear myocardial perfusion imaging use. J Am Med Assoc 2014;311:1248-1249 [letter to the editor] 2. Rozanski A, Gransar H, Hayes SW, et al: Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing. J Am Coll Cardiol 2013;61:1054-1065 3. Travin MI: Letter from the Guest Editor: Update in Cardiovascular Nuclear Medicine. Semin Nucl Med 2014;44:230-231 4. Travin MI: Cardiac Radionuclide Imaging to Assess Patients With Heart Failure. Semin Nucl Med 2014;44:294-313 5. Soman P, Chen J: Left Ventricular Dyssynchrony Assessment Using Myocardial Single-Photon Emission CT. Semin Nucl Med 2014;44:314-319
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