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Evidence-based Cardiovascular Imaging

A.  Understand the principles of technology assessment.
B. Be aware of cardiovascular risk factors with an understanding of the Framingham risk score.
C. Understand the imaging risk markers for atheromatous disease, notably coronary calcium score on CT and intimo-medial thickness on carotid ultrasound.
D.  Understand how the calcium score affects management above and beyond the Framingham risk score
E.  Appreciate the arguments for and against screening for cardiovascular disease using coronary calcium score
F.  Appreciate the competing modalities for detection of chronic ischemic heart disease including myocardial perfusion scintigraphy, stress echo, stress MRI, cardiac CT, exercise ECG and PET

Assessment of Myocardial Perfusion in Coronary Artery Disease by Magnetic Resonance : A Comparison With Positron Emission Tomography and Coronary Angiography 
J. Schwitter, D. Nanz, S. Kneifel, K. Bertschinger, M. Büchi, P. R. Knüsel, B. Marincek, T. F. Lüscher, and G. K. von Schulthess 

    Circulation. 2001;103:2230-2235, doi:10.1161/01.CIR.103.18.2230                
G.  Appreciate the competing modalities for detection of acute coronary syndrome
  • Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain: A Scientific Statement From the American Heart Association 
    Ezra A. Amsterdam, J. Douglas Kirk, David A. Bluemke, Deborah Diercks, Michael E. Farkouh, J. Lee Garvey, Michael C. Kontos, James McCord, Todd D. Miller, Anthony Morise, L. Kristin Newby, Frederick L. Ruberg, Kristine Anne Scordo, Paul D. Thompson, and on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research 
    Circulation. 2010;122:1756-1776, published online before print July 26 2010, doi:10.1161/CIR.0b013e3181ec61df 
H.  Have an understanding for the clinical contexts in which a high negative predictive value is important for those in which a high positive predictive value is necessary.
I. Be aware of some of the research comparing cardiac CT with myocardial perfusion imaging.
  • Diagnostic Performance of Coronary Angiography by 64-Row CT
    Julie M. Miller, M.D., Carlos E. Rochitte, M.D., Marc Dewey, M.D., Armin Arbab-Zadeh, M.D., Hiroyuki Niinuma, M.D., Ph.D., Ilan Gottlieb, M.D., Narinder Paul, M.D., Melvin E. Clouse, M.D., Edward P. Shapiro, M.D., John Hoe, M.D., Albert C. Lardo, Ph.D., David E. Bush, M.D., Albert de Roos, M.D., Christopher Cox, Ph.D., Jeffery Brinker, M.D., and João A.C. Lima, M.D.
    N Engl J Med 2008; 359:2324-2336 November 27, 2008

J. Understand the controversies pertaining to cardiac CT particularly with regards to its costs and the costs of treating incidental findings.
K. Appreciate the role of late gadolinium MRI in risk stratifying patients with various forms of cardiomyopathy. Understand the additional prognostic information offered.
L. Understand the seminal study involving survival analysis of patients with hypertrophic cardiomyopathy and scar as detected on late gadolinium MRI.
  • Myocardial Fibrosis as an Early Manifestation of Hypertrophic Cardiomyopathy
    Carolyn Y. Ho, M.D., Begoña López, Ph.D., Otavio R. Coelho-Filho, M.D., Neal K. Lakdawala, M.D., Allison L. Cirino, M.S., C.G.C., Petr Jarolim, M.D., Ph.D., Raymond Kwong, M.D., Arantxa González, Ph.D., Steven D. Colan, M.D., J.G. Seidman, Ph.D., Javier Díez, M.D., Ph.D., and Christine E. Seidman, M.D.
    N Engl J Med 2010; 363:552-563August 5, 2010
M. Appreciate how MRI guides the decision to revascularize and how this is superior to PET and myocardial perfusion imaging.
N. Understand how MRI functions as a biomarker for iron involvement of the heart and how this has revolutionized survival of patients with thalassemia.
O. Understand how MRI helps with the decision who should get an ICD and who should receive cardiac resynchronization therapy.
P. Understand how CMR reduces sample size in clinical trial which use CMR parameters as end points, in comparison to echo