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Coronary Artery Disease: HELP
Articles by Rory Hachamovitch
Based on 31 articles published since 2010
(Why 31 articles?)
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Between 2010 and 2020, R. Hachamovitch wrote the following 31 articles about Coronary Artery Disease.
 
+ Citations + Abstracts
Pages: 1 · 2
1 Editorial Identifying Likelihood of Obstructive Coronary Disease in Patients With a Calcium Score of Zero: Separating the Wheat From the Chaff. 2019

Ramchand, Jay / Jaber, Wael / Hachamovitch, Rory. ·Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH. ·Circ Cardiovasc Imaging · Pubmed #31526299.

ABSTRACT: -- No abstract --

2 Editorial Modeling Fractional Flow Reserve: Developing an Estimate of a Better Mousetrap. 2018

Hachamovitch, Rory. ·Cardiovascular Imaging Section, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Ohio. ·Circ Cardiovasc Imaging · Pubmed #29895716.

ABSTRACT: -- No abstract --

3 Editorial Updating Algorithms for Predicting Pre-Test Likelihood of Coronary Artery Disease: A Cure for Inappropriate Testing? 2018

Hachamovitch, Rory. ·Cardiovascular Imaging Section, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio. Electronic address: hachamr@ccf.org. ·JACC Cardiovasc Imaging · Pubmed #28624399.

ABSTRACT: -- No abstract --

4 Editorial Has anyone been listening? Post-SPECT MPI referral rates to catheterization. 2017

Hill, Elizabeth / Hachamovitch, Rory. ·Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. · Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, J1-5, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. hachamr@ccf.org. ·J Nucl Cardiol · Pubmed #27357810.

ABSTRACT: -- No abstract --

5 Editorial Evaluating the clinical impact of cardiovascular imaging: is a risk-based stratification paradigm relevant? 2013

Schoenhagen, Paul / Hachamovitch, Rory. · ·J Am Coll Cardiol · Pubmed #23219301.

ABSTRACT: -- No abstract --

6 Editorial What should we expect in a prognosis study in 2012? 2012

Hachamovitch, Rory. · ·J Nucl Cardiol · Pubmed #22936467.

ABSTRACT: -- No abstract --

7 Editorial Coronary CT angiography and comparative effectiveness research prognostic value of atherosclerotic disease burden in appropriately indicated clinical examinations. 2011

Schoenhagen, Paul / Hachamovitch, Rory / Achenbach, Stephan. · ·JACC Cardiovasc Imaging · Pubmed #21565736.

ABSTRACT: -- No abstract --

8 Review Evolving, innovating, and revolutionary changes in cardiovascular imaging: We've only just begun! 2018

Shaw, Leslee J / Hachamovitch, Rory / Min, James K / Di Carli, Marcelo / Mieres, Jennifer H / Phillips, Lawrence / Blankstein, Ron / Einstein, Andrew / Taqueti, Viviany R / Hendel, Robert / Berman, Daniel S. ·Emory University School of Medicine, Atlanta, GA, USA. lshaw3@emory.edu. · Emory University Clinical Cardiovascular Research Institute, 1462 Clifton Rd NE, Room 529, Atlanta, GA, 30324, USA. lshaw3@emory.edu. · Cleveland Clinic Foundation, Cleveland, OH, USA. · Weill Cornell Medical College, New York, NY, USA. · Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. · Hofstra University School of Medicine, New York, NY, USA. · New York University School of Medicine, New York, NY, USA. · Columbia University, New York, NY, USA. · Tulane University School of Medicine, New Orleans, LA, USA. · Cedars-Sinai Heart Institute, Los Angeles, CA, USA. ·J Nucl Cardiol · Pubmed #29468466.

ABSTRACT: In this review, we highlight the need for innovation and creativity to reinvent the field of nuclear cardiology. Revolutionary ideas brought forth today are needed to create greater value in patient care and highlight the need for more contemporary evidence supporting the use of nuclear cardiology practices. We put forth discussions on the need for disruptive innovation in imaging-guided care that places the imager as a central force in care coordination. Value-based nuclear cardiology is defined as care that is both efficient and effective. Novel testing strategies that defer testing in lower risk patients are examples of the kind of innovation needed in today's healthcare environment. A major focus of current research is the evolution of the importance of ischemia and the prognostic significance of non-obstructive atherosclerotic plaque and coronary microvascular dysfunction. Embracing novel paradigms, such as this, can aid in the development of optimal strategies for coronary disease management. We hope that our article will spurn the field toward greater innovation and focus on transformative imaging leading the way for new generations of novel cardiovascular care.

9 Review The elusive role of myocardial perfusion imaging in stable ischemic heart disease: Is ISCHEMIA the answer? 2017

Xie, Joe X / Winchester, David E / Phillips, Lawrence M / Hachamovitch, Rory / Berman, Daniel S / Blankstein, Ron / Di Carli, Marcelo F / Miller, Todd D / Al-Mallah, Mouaz H / Shaw, Leslee J. ·Department of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, Georgia. joe.xie@emory.edu. · Department of Cardiology, University of Florida College of Medicine, Gainesville, FL, USA. · Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA. · Department of Cardiology, Cleveland Clinic, Cleveland, OH, USA. · Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA. · Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA. · Department of Cardiology, Mayo Clinic, Rochester, MN, USA. · King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia. · Department of Cardiology, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, Georgia. ·J Nucl Cardiol · Pubmed #28752313.

ABSTRACT: The assessment of ischemia through myocardial perfusion imaging (MPI) is widely accepted as an index step in the diagnostic evaluation of stable ischemic heart disease (SIHD). Numerous observational studies have characterized the prognostic significance of ischemia extent and severity. However, the role of ischemia in directing downstream SIHD care including coronary revascularization has remained elusive as reductions in ischemic burden have not translated to improved clinical outcomes in randomized trials. Importantly, selection bias leading to the inclusion of many low risk patients with minimal ischemia have narrowed the generalizability of prior studies along with other limitations. Accordingly, an ongoing randomized controlled trial entitled ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) will compare an invasive coronary revascularization strategy vs a conservative medical therapy approach among stable patients with moderate to severe ischemia. The results of ISCHEMIA may have a substantial impact on the management of SIHD and better define the role of MPI in current SIHD pathways of care.

10 Review Clinical decision making with myocardial perfusion imaging in patients with known or suspected coronary artery disease. 2014

Cremer, Paul / Hachamovitch, Rory / Tamarappoo, Balaji. ·Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH. · Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH. Electronic address: tamarab@ccf.org. ·Semin Nucl Med · Pubmed #24948154.

ABSTRACT: Myocardial perfusion imaging (MPI) to diagnose coronary artery disease (CAD) is best performed in patients with intermediate pretest likelihood of disease; unfortunately, pretest likelihood is often overestimated, resulting in the inappropriate use of perfusion imaging. A good functional capacity often predicts low risk, and MPI for diagnosing CAD should be reserved for individuals with poor exercise capacity, abnormal resting electrocardiography, or an intermediate or high probability of CAD. With respect to anatomy-based testing, coronary CT angiography has a good negative predictive value, but stenosis severity correlates poorly with ischemia. Therefore decision making with respect to revascularization may be limited when a purely noninvasive anatomical test is used. Regarding perfusion imaging, the diagnostic accuracies of SPECT, PET, and cardiac magnetic resonance are similar, though fewer studies are available with cardiac magnetic resonance. PET coronary flow reserve may offer a negative predictive value sufficiently high to exclude severe CAD such that patients with mild to moderate reversible perfusion defects can forego invasive angiography. In addition, combined anatomical and perfusion-based imaging may eventually offer a definitive evaluation for diagnosing CAD, even in higher risk patients. Any remarkable findings on single-photon emission computed tomography and PET MPI studies are valuable for prognostication. Furthermore, assessment of myocardial blood flow with PET is particularly powerful for prognostication as it reflects the end result of many processes that lead to atherosclerosis. Decision making with respect to revascularization is limited for cardiac MRI and PET MPI. In contrast, retrospective radionuclide studies have identified an ischemic threshold, but randomized trials are needed. In patients with at least moderately reduced left ventricular systolic function, viable myocardium as assessed by PET or MRI, appears to identify patients who benefit from revascularization, but well-executed randomized trials are lacking.

11 Review Assessing the prognostic implications of myocardial perfusion studies: identification of patients at risk vs patients who may benefit from intervention? 2014

Cremer, Paul / Hachamovitch, Rory. ·Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5 9500 Euclid Avenue, Cleveland, OH, 44915, USA. ·Curr Cardiol Rep · Pubmed #24585113.

ABSTRACT: Stress myocardial perfusion imaging (MPI) has a well-established role in improving risk stratification. Recent analyses, compared with older data, suggest that the yield of stress MPI has decreased. In part, this trend relates to testing patients with heterogeneous, but improved, risk factor modification. In this setting, positron emission tomography with myocardial flow reserve enhances risk stratification as it reflects the end result of atherosclerosis. Recent studies have also emphasized the clinical impact of incremental risk stratification by assessing net reclassification improvement (NRI). Previous retrospective studies have favored an ischemic threshold to select patients that benefit from revascularization, but this finding has not been corroborated in randomized trials. However, no large randomized trial has directly tested a strategy of revascularization for patients with at least a moderate amount of ischemia at risk. Unfortunately, even when faced with a significantly abnormal MPI result, subsequent action is too often absent.

12 Review Importance of residual myocardial ischemia after intervention in the genesis of cardiovascular events among patients with chronic coronary artery disease. 2011

Shaw, Leslee J / Hachamovitch, Rory / Min, James / Berman, Daniel S. ·Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA. ·Curr Cardiol Rep · Pubmed #21656198.

ABSTRACT: Recent randomized clinical trials support the strategy of ischemia-guided management for patients with stable ischemic heart disease. The application of serial testing to examine the efficacy of therapeutic intervention for ischemia suppression and to document the extent and severity of ischemia provides an important means to guide clinical decision making. This review provides a synopsis of available evidence on serial testing and meaningful thresholds for application of paired rest/stress myocardial perfusion single photon emission computed tomography imaging.

13 Review SPECT/PET myocardial perfusion imaging versus coronary CT angiography in patients with known or suspected CAD. 2010

Berman, D S / Shaw, L J / Min, J K / Hachamovitch, R / Abidov, A / Germano, G / Hayes, S W / Friedman, J D / Thomson, L E J / Kang, X / Slomka, P / Rozanski, A. ·Department of Imaging, Cedars-Sinai Medical Center, CSMC Burns and Allen Research Institute, Los Angeles, California 90048, USA. bermand@cshs.org ·Q J Nucl Med Mol Imaging · Pubmed #20592682.

ABSTRACT: Stress SPECT myocardial perfusion imaging (MPI) is the most commonly utilized stress imaging technique for patients with suspected or known coronary artery disease (CAD) and has a robust evidence base including the support of numerous clinical guidelines. Gated SPECT is a well-established noninvasive imaging modalities that is a core element in evaluation of patients with both acute and stable chest pain syndromes. Over the past decade, PET has become increasingly used for the same applications. By comparison, cardiac computed tomography (CT) is a more recently developed method, providing non-invasive approaches for imaging coronary atherosclerosis and coronary artery stenosis. Non-contrast CT for imaging the extent of coronary artery calcification (CAC), in clinical use since the mid-1990's, has a very extensive evidence base supporting its use in CAD prevention. While contrast-enhanced CT for noninvasive CT coronary angiography (CCTA) is relatively new, it has already developed an extensive base of evidence regarding diagnosing obstructive CAD and more recently evidence has emerged regarding its prognostic value. It is likely that non-contrast CT or CCTA for assessment of extent of atherosclerosis will become an increasing part of mainstream cardiovascular imaging practices as a first line test. In some patients, further ischemia testing with MPI will be required. Similarly, MPI will continue to be widely used as a first-line test, and in some patients, further anatomic definition of atherosclerosis with CT will also be appropriate. This review will provide a synopsis of the available literature on imaging that integrates both CT and MPI in strategies for the assessment of asymptomatic patients for their atherosclerotic coronary disease burden and risk as well as symptomatic patients for diagnosis and guiding management. We propose possible strategies through which imaging might be used to identify asymptomatic candidates for more intensive prevention and risk factor modification strategies as well as symptomatic patients who would benefit from referral to invasive coronary angiography for consideration of revascularization.

14 Article Quantitative Coronary Flow Capacity for Risk Stratification and Clinical Decision Making: Is It Ready for Prime Time? 2019

Di Carli, Marcelo F / Hachamovitch, Rory. ·Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts mdicarli@bwh.harvard.edu. · Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. · Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and. · Cardiovascular Imaging Section, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. ·J Nucl Med · Pubmed #30733315.

ABSTRACT: -- No abstract --

15 Article Computed Tomographic Coronary Angiography Identification of Plaque Inflammation: An Imaging Target Within Reach? 2018

Hachamovitch, Rory / Menon, Venu. ·Cardiovascular Imaging Section, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. ·JAMA Cardiol · Pubmed #30027263.

ABSTRACT: -- No abstract --

16 Article Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease effectively identifies revascularization candidates. 2015

Hachamovitch, Rory. ·From the Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH. hachamr@ccf.org. ·Circ Cardiovasc Imaging · Pubmed #25977301.

ABSTRACT: -- No abstract --

17 Article Global coronary flow reserve is associated with adverse cardiovascular events independently of luminal angiographic severity and modifies the effect of early revascularization. 2015

Taqueti, Viviany R / Hachamovitch, Rory / Murthy, Venkatesh L / Naya, Masanao / Foster, Courtney R / Hainer, Jon / Dorbala, Sharmila / Blankstein, Ron / Di Carli, Marcelo F. ·From the Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (V.R.T., M.N., C.R.F., J.H., S.D., R.B., M.F.D.C.) · Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (R.H.) · and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.). ·Circulation · Pubmed #25400060.

ABSTRACT: BACKGROUND: Coronary flow reserve (CFR), an integrated measure of focal, diffuse, and small-vessel coronary artery disease (CAD), identifies patients at risk for cardiac death. We sought to determine the association between CFR, angiographic CAD, and cardiovascular outcomes. METHODS AND RESULTS: Consecutive patients (n=329) referred for invasive coronary angiography after stress testing with myocardial perfusion positron emission tomography were followed (median 3.1 years) for cardiovascular death and heart failure admission. The extent and severity of angiographic disease were estimated with the use of the CAD prognostic index, and CFR was measured noninvasively by positron emission tomography. A modest inverse correlation was seen between CFR and CAD prognostic index (r=-0.26; P<0.0001). After adjustment for clinical risk score, ejection fraction, global ischemia, and early revascularization, CFR and CAD prognostic index were independently associated with events (hazard ratio for unit decrease in CFR, 2.02; 95% confidence interval, 1.20-3.40; P=0.008; hazard ratio for 10-U increase in CAD prognostic index, 1.17; 95% confidence interval, 1.01-1.34; P=0.032). Subjects with low CFR experienced rates of events similar to those of subjects with high angiographic scores, and those with low CFR or high CAD prognostic index showed the highest risk of events (P=0.001). There was a significant interaction (P=0.039) between CFR and early revascularization by coronary artery bypass grafting, such that patients with low CFR who underwent coronary artery bypass grafting, but not percutaneous coronary intervention, experienced event rates comparable to those with preserved CFR, independently of revascularization. CONCLUSIONS: CFR was associated with outcomes independently of angiographic CAD and modified the effect of early revascularization. Diffuse atherosclerosis and associated microvascular dysfunction may contribute to the pathophysiology of cardiovascular death and heart failure, and impact the outcomes of revascularization.

18 Article Coronary artery disease detected by coronary computed tomographic angiography is associated with intensification of preventive medical therapy and lower low-density lipoprotein cholesterol. 2014

Hulten, Edward / Bittencourt, Marcio Sommer / Singh, Avinainder / O'Leary, Daniel / Christman, Mitalee P / Osmani, Wafa / Abbara, Suhny / Steigner, Michael L / Truong, Quynh A / Nasir, Khurram / Rybicki, Frank F / Klein, Josh / Hainer, Jon / Brady, Thomas J / Hoffmann, Udo / Ghoshhajra, Brian B / Hachamovitch, Rory / Di Carli, Marcelo F / Blankstein, Ron. ·From the Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA (E.H., M.S.B., A.S., D.O., M.P.C., W.O., M.L.S., F.F.R., J.K., J.H., M.F.D.C., R.B.) · Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD (E.H.) · Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil (M.S.B.) · Cardiac MR PET CT Program, Department of Radiology, Division of Cardiac Imaging (S.A., T.J.B., U.H., B.B.G.), and Division of Cardiology (Q.A.T.), Massachusetts General Hospital, Harvard Medical School, Boston · Center for Wellness and Prevention Research, Baptist Health South Florida, Miami (K.N.) · and Cleveland Clinic Foundation, OH (R.H.). ·Circ Cardiovasc Imaging · Pubmed #24906356.

ABSTRACT: BACKGROUND: Coronary computed tomographic angiography (CCTA) is an accurate test for the identification of coronary artery disease (CAD), yet the impact of CCTA results on subsequent medical therapy and risk factors has not been widely reported. METHODS AND RESULTS: We identified consecutive patients aged >18 years without prior CAD who underwent CCTA from 2004 to 2011 and had complete data on medications before and after CCTA. CCTA results were categorized as no CAD, <50% stenosis, and ≥50% stenosis. Based on the number of involved segments, extent of disease was categorized as nonextensive (≤4 segments) or extensive CAD (>4 segments). Electronic medical records and patient interviews were reviewed blinded to CCTA findings to assess initiation of aspirin and intensification of lipid-lowering therapies. Survival analysis was performed to evaluate intensification of lipid therapy as a predictor of cardiovascular death or nonfatal myocardial infarction. Among 2839 patients with mean follow-up of 3.6 years, the odds of physician intensification of lipid-lowering therapy significantly increased for those with nonobstructive CAD (odds ratio, 3.6; 95% confidence interval, 2.9-4.9; P<0.001) and obstructive CAD (odds ratio, 5.6; 95% confidence interval, 4.3-7.3; P<0.001). Low-density lipoprotein cholesterol levels declined significantly in association with intensification of lipid-lowering therapy after CCTA in all patient subgroups. In a hypothesis-generating analysis, among patients with nonobstructive but extensive CAD, statin use after CCTA was associated with a reduction in cardiovascular death or myocardial infarction (hazards ratio, 0.18; 95% confidence interval, 0.05-0.66; P=0.01). CONCLUSIONS: Abnormal CCTA findings are associated with downstream intensification in statin and aspirin therapy. In particular, CCTA may lead to increased use of prognostically beneficial therapies in patients identified as having extensive, nonobstructive CAD.

19 Article Ischemic burden by 3-dimensional myocardial perfusion cardiovascular magnetic resonance: comparison with myocardial perfusion scintigraphy. 2014

Jogiya, Roy / Morton, Geraint / De Silva, Kalpa / Reyes, Eliana / Hachamovitch, Rory / Kozerke, Sebastian / Nagel, Eike / Underwood, S Richard / Plein, Sven. ·From the King's College London BHF Centre of Excellence, NIHR Biomedical Research Centre and Welcome Trust and EPSRC Medical Engineering Centre at Guy's and St. Thomas' NHS Foundation Trust, Division of Imaging Sciences, The Rayne Institute, London, United Kingdom (R.J., G.M., S.K., E.N., S.P.) · King's College London BHF Centre of Excellence, NIHR Biomedical Research Centre at Guy's and St. Thomas' NHS Foundation Trust, Cardiovascular Division, The Rayne Institute, London, United Kingdom (K.D.S.) · Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, United Kingdom (E.R., S.R.U.) · Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH (R.H.) · Institute for Biomedical Engineering, University and ETH Zurich, Switzerland (S.K.) · and Multidisciplinary Cardiovascular Research Centre & Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, United Kingdom (S.P.). ·Circ Cardiovasc Imaging · Pubmed #24867884.

ABSTRACT: BACKGROUND: The extent and severity of ischemia on myocardial perfusion scintigraphy (MPS) is commonly used to risk-stratify patients with coronary artery disease. Estimation of ischemic burden by cardiovascular magnetic resonance (CMR) with conventional 2-dimensional myocardial perfusion methods is limited by incomplete cardiac coverage. More recently developed 3-dimensional (3D) myocardial perfusion CMR, however, provides whole-heart coverage. The aim of this study was to compare ischemic burden on 3D myocardial perfusion CMR with (99m)Tc-tetrofosmin MPS. METHODS AND RESULTS: Forty-five patients who had undergone clinically indicated MPS underwent rest and adenosine stress 3D myocardial perfusion and late gadolinium enhancement CMR. Summed stress and rest scores were calculated for MPS and CMR using a 17-segment model and expressed as a percentage of the maximal possible score. Ischemic burden was defined as the difference between stress and rest scores. 3D myocardial perfusion CMR and MPS agreed in 38 of the 45 patients for the detection of any inducible ischemia. The mean ischemic burden for MPS and CMR was similar (7.5±8.9% versus 6.8±9.5%, respectively, P=0.82) with a strong correlation between techniques (rs=0.70, P<0.001). In a subset of 33 patients who underwent clinically indicated invasive coronary angiography, sensitivities and specificities of the 2 techniques to detect angiographic coronary artery disease were similar (McNemar P=0.45). CONCLUSIONS: 3D myocardial perfusion CMR is an alternative to MPS for detecting the presence and rating the severity of ischemia.

20 Article Economic outcomes in the Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in Coronary Artery Disease registry: the SPARC Study. 2014

Hlatky, Mark A / Shilane, David / Hachamovitch, Rory / Dicarli, Marcelo F / Anonymous2590788. ·Stanford University School of Medicine, Stanford, California. Electronic address: hlatky@stanford.edu. · Stanford University School of Medicine, Stanford, California. · Cleveland Clinic, Cleveland, Ohio. · Harvard Medical School, Boston, Massachusetts. ·J Am Coll Cardiol · Pubmed #24636556.

ABSTRACT: OBJECTIVES: The goal of this study was to compare the economic outcomes of patients undergoing different noninvasive tests to evaluate suspected coronary artery disease (CAD). BACKGROUND: Evaluation of noninvasive tests is shifting to an assessment of their effect on clinical outcomes rather than on their diagnostic accuracy. Economic outcomes of testing are particularly important in light of rising medical care costs. METHODS: We used an observational registry of 1,703 patients who underwent coronary computed tomography angiography (CTA) (n = 590), positron emission tomography (PET) (n = 548), or single-photon emission computed tomography (SPECT) (n = 565) for diagnosis of suspected CAD at 1 of 41 centers. We followed patients for 2 years, and documented resource use, medical costs for CAD, and clinical outcomes. We used multivariable analysis and propensity score matching to control for differences in baseline characteristics. RESULTS: Two-year costs were highest after PET ($6,647, 95% confidence interval [CI]: $5,896 to $7,397), intermediate after CTA ($4,909, 95% CI: $4,378 to $5,440), and lowest after SPECT ($3,965, 95% CI: $3,520 to $4,411). After multivariable adjustment, CTA costs were 15% higher than SPECT (p < 0.01), and PET costs were 22% higher than SPECT (p < 0.0001). Two-year mortality was 0.7% after CTA, 1.6% after SPECT, and 5.5% after PET. The incremental cost-effectiveness ratio for CTA compared with SPECT was $11,700 per life-year added, but was uncertain, with higher costs and higher mortality in 13% of bootstrap replications. Patients undergoing PET had higher costs and higher mortality than patients undergoing SPECT in 98% of bootstrap replications. CONCLUSIONS: Costs were significantly lower after using SPECT rather than CTA or PET in the evaluation of suspected coronary disease. SPECT was economically attractive compared with PET, whereas CTA was associated with higher costs and no significant difference in mortality compared with SPECT.

21 Article Myocardial scar burden predicts survival benefit with implantable cardioverter defibrillator implantation in patients with severe ischaemic cardiomyopathy: influence of gender. 2014

Kwon, Deborah H / Hachamovitch, Rory / Adeniyi, Aderonke / Nutter, Benjamin / Popovic, Zoran B / Wilkoff, Bruce L / Desai, Milind Y / Flamm, Scott D / Marwick, Thomas. ·Heart and Vascular Institute, Cleveland Clinic, , Cleveland, Ohio, USA. ·Heart · Pubmed #24186562.

ABSTRACT: OBJECTIVE: We sought to assess the impact of myocardial scar burden (MSB) on the association between implantable cardioverter defibrillator (ICD) implantation and mortality in patients with ischaemic cardiomyopathy (ICM) and left ventricular EF ≤ 40%. In addition, we sought to determine the impact of gender on survival benefit with ICD implantation. DESIGN: Retrospective observational study. SETTING: Single US tertiary care centre. PATIENTS: Consecutive patients with significant ICM who underwent delayed hyperenhancement-MRI between 2002 and 2006. INTERVENTIONS: ICD implantation. MAIN OUTCOME MEASURES: All-cause mortality and cardiac transplantation. RESULTS: Follow-up of 450 consecutive patients, over a mean of 5.8 years, identified 186 deaths. Cox proportional hazard modelling was used to evaluate associations among MSB, gender and ICD with respect to all-cause death as the primary endpoint. ICDs were implanted in 163 (36%) patients. On multivariable analysis, Scar% (χ² 28.21, p<0.001), Gender (χ² 12.39, p=0.015) and ICD (χ² 9.57, p=0.022) were independent predictors of mortality after adjusting for multiple parameters. An interaction between MSB×ICD (χ² 9.47, p=0.009) demonstrated significant differential survival with ICD based on MSB severity. Additionally, Scar%×ICD×Gender (χ² 6.18, p=0.048) suggested that men with larger MSB had significant survival benefit with ICD, but men with smaller MSB derived limited benefit with ICD implantation. However, the inverse relationship was found in women. CONCLUSIONS: MSB is a powerful independent predictor of mortality in patients with and without ICD implantation. In addition, MSB may predict gender-based significant differences in survival benefit from ICDs in patients with severe ICM.

22 Article Appropriate test selection for single-photon emission computed tomography imaging: association with clinical risk, posttest management, and outcomes. 2013

Aldweib, Nael / Negishi, Kazuaki / Seicean, Sinziana / Jaber, Wael A / Hachamovitch, Rory / Cerqueira, Manuel / Marwick, Thomas H. ·Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH and Menzies Research Institute Tasmania. ·Am Heart J · Pubmed #24016510.

ABSTRACT: BACKGROUND: Appropriate use criteria (AUC) for stress single-photon emission computed tomography (SPECT) are only one step in appropriate use of imaging. Other steps include pretest clinical risk evaluation and optimal management responses. We sought to understand the link between AUC, risk evaluation, management, and outcome. METHODS: We used AUC to classify 1,199 consecutive patients (63.8 ± 12.5 years, 56% male) undergoing SPECT as inappropriate, uncertain, and appropriate. Framingham score for asymptomatic patients and Bethesda angina score for symptomatic patients were used to classify patients into high (≥5%/y), intermediate, and low (≤1%/y) risk. Subsequent patient management was defined as appropriate or inappropriate based on the concordance between management decisions and the SPECT result. Patients were followed up for a median of 4.8 years, and cause of death was obtained from the social security death registry. RESULTS: Overall, 62% of SPECTs were appropriate, 18% inappropriate, and 20% uncertain (only 5 were unclassified). Of 324 low-risk studies, 108 (33%) were inappropriate, compared with 94 (15%) of 621 intermediate-risk and 1 (1%) of 160 high-risk studies (P < .001). There were 79 events, with outcomes of inappropriate patients better than uncertain and appropriate patients. Management was appropriate in 986 (89%), and appropriateness of patient management was unrelated to AUC (P = .65). CONCLUSION: Pretest clinical risk evaluation may be helpful in appropriateness assessment because very few high-risk patients are inappropriate, but almost half of low-risk patients are inappropriate or uncertain. Appropriate patient management is independent of appropriateness of testing.

23 Article Impact of ischemia and scar on therapeutic benefit of myocardial revascularization. 2013

Hachamovitch, R. ·Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Euclid Avenue, Cleveland, Ohio 44195, USA. hachamr@ccf.org ·Herz · Pubmed #23625299.

ABSTRACT: The question of how to optimally manage coronary artery disease (CAD) has been a challenge for the cardiology community. The results of early, large randomized clinical trials (RCTs) comparing strategies of medical therapy alone versus revascularization plus medical therapy in patients with stable CAD suggested a survival advantage for a revascularization strategy in the setting of more advanced, higher-risk CAD (left main, three-vessel CAD), but a superiority of medical therapy in patients with more limited, relatively lower-risk CAD (one vessel, limited two-vessel CAD). The results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials redefined the management of CAD, supporting the concept that the impact of aggressively applied modern "medical therapy" on patient survival and patient-reported outcomes is not further improved by the addition of percutaneous intervention. On the other hand, RCTs incorporating fractional flow reserve have shown that this physiologic metric can help identify which patients will benefit from a revascularization strategy. This paradigm has been extended to the use of myocardial perfusion imaging-identified ischemia to determine which patients may have enhanced survival with early revascularization versus medical therapy. Although data from a series of observational studies suggest that inducible ischemia on myocardial perfusion scintigraphy can identify revascularization candidates, several studies, including substudies from major RCTs, do not support this idea. Until RCTs comparing revascularization with medical therapy strategies are performed, many questions remain open. The correct thresholds for treatment, the metric to guide treatment, and how revascularization should be performed are as yet undefined.

24 Article Impact of repeat myocardial revascularization on outcome in patients with silent ischemia after previous revascularization. 2013

Aldweib, Nael / Negishi, Kazuaki / Hachamovitch, Rory / Jaber, Wael A / Seicean, Sinziana / Marwick, Thomas H. ·Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA. ·J Am Coll Cardiol · Pubmed #23500275.

ABSTRACT: OBJECTIVES: This study sought to compare the survival of asymptomatic patients with previous revascularization and ischemia, who subsequently underwent repeat revascularization or medical therapy (MT). BACKGROUND: Coronary artery disease is progressive and recurring; thus, stress myocardial perfusion scintigraphy (MPS) is widely used to identify ischemia in patients with previous revascularization. METHODS: Of 6,750 patients with previous revascularization undergoing MPS between January 1, 2005, and December 31, 2007, we identified 769 patients (age 67.7 ± 9.5 years; 85% men) who had ischemia and were asymptomatic. A propensity score was developed to express the associations of revascularization. Patients were followed up over a median of 5.7 years (interquartile range: 4.7 to 6.4 years) for all-cause death. A Cox proportional hazards model was used to identify the association of revascularization with all-cause death, with and without adjustment for the propensity score. The model was repeated in propensity-matched groups undergoing MT versus revascularization. RESULTS: Among 769 patients, 115 (15%) underwent revascularization a median of 13 days (interquartile range: 6 to 31 days) after MPS. There were 142 deaths; mortality with MT and revascularization were 18.3% and 19.1% (p = 0.84). In a Cox proportional hazards model (chi-square test = 89.4) adjusting for baseline characteristics, type of previous revascularization, MPS data, and propensity scores, only age and hypercholesterolemia but not revascularization were associated with mortality. This result was confirmed in a propensity-matched group. CONCLUSIONS: Asymptomatic patients with previous revascularization and inducible ischemia on MPS realize no survival benefit from repeat revascularization. In this group of post-revascularization patients, an ischemia-based treatment strategy did not alter mortality.

25 Article Association of epicardial fat, hypertension, subclinical coronary artery disease, and metabolic syndrome with left ventricular diastolic dysfunction. 2012

Cavalcante, João L / Tamarappoo, Balaji K / Hachamovitch, Rory / Kwon, Deborah H / Alraies, M Chadi / Halliburton, Sandra / Schoenhagen, Paul / Dey, Damini / Berman, Daniel S / Marwick, Thomas H. ·Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA. ·Am J Cardiol · Pubmed #22980968.

ABSTRACT: Epicardial fat is a metabolically active fat depot that is strongly associated with obesity, metabolic syndrome, and coronary artery disease (CAD). The relation of epicardial fat to diastolic function is unknown. We sought to (1) understand the relation of epicardial fat volume (EFV) to diastolic function and (2) understand the role of EFV in relation to potential risk factors (hypertension, subclinical CAD, and metabolic syndrome) of diastolic dysfunction in apparently healthy subjects with preserved systolic function and no history of CAD. We studied 110 consecutive subjects (65% men, 55 ± 13 years old, mean body mass index 28 ± 5 kg/m(2)) who underwent cardiac computed tomography and transthoracic echocardiography within 6 months as part of a self-referred health screening program. Exclusion criteria included history of CAD, significant valvular disease, systolic dysfunction (left ventricular ejection fraction <50%). Diastolic function was defined according to American Society of Echocardiography guidelines. EFV was measured using validated cardiac computed tomographic software by 2 independent cardiologists blinded to clinical and echocardiographic data. Hypertension and metabolic syndrome were present in 60% and 45%, respectively. Subclinical CAD was identified in 20% of the cohort. Diastolic dysfunction was present in 45 patients. EFV was an independent predictor of diastolic dysfunction, mean peak early diastolic mitral annular velocity, and ratio of early diastolic filling to peak early diastolic mitral annular velocity (p = 0.01, <0.0001, and 0.001, respectively) with incremental contribution to other clinical factors. In conclusion, EFV is an independent predictor of impaired diastolic function in apparently healthy overweight patients even after accounting for associated co-morbidities such as metabolic syndrome, hypertension, and subclinical CAD.

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