{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzmnfd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzmnfd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/10\\\/24\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/10\\\/24\u0022}],\u0022ac\u0022:{\u0022spmdc;10\\\/10\\\/24\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;10\\\/10\\\/24\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe field of cardiovascular (CV) imaging is facing challenges, such as high growth rates in usage resulting in increased costs and, in many cases, a lack of demonstrable utility. This article discusses emerging trends and challenges in CV imaging.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EImaging Modalities\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiac Imaging Techniques\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAmong the 12 million cardiovascular (CV) imaging studies that are performed each year, many are used to assess patient risk and guide patient management decisions regarding medical therapy and revascularization. Ideally, decisions regarding diagnosis, risk stratification, and treatment are made on the basis of extensive clinical evidence. However, the field of CV imaging is facing challenges, such as high growth rates in usage resulting in increased costs and, in many cases, a lack of demonstrable utility. Leslee Shaw, MD, Emory University School of Medicine, Atlanta, Georgia, USA, discussed emerging trends and challenges in CV imaging.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EDr. Shaw and colleagues recently examined several trends in the use of CV imaging modalities [Shaw LJ et al. \u003Cem\u003EJACC Cardiovas Imaging\u003C\/em\u003E 2010]. With rapid and continued growth over the past decade, cardiac imaging now accounts for $80 billion in annual health care costs. In 1998, 26% of cardiology office visits included an order for cardiac imaging. By 2008, this number increased to 30% among patients aged 45 to 64 years and increased to 36% among patients aged 65 years or older. Several factors have contributed to the expanded use of CV imaging, including:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \u003Cp id=\u0022p-4\u0022\u003EIncreasing consumer demands\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \u003Cp id=\u0022p-5\u0022\u003EThe growing supply of new imaging technologies\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \u003Cp id=\u0022p-6\u0022\u003EAn aging population with more functional limitations\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-7\u0022\u003ENew consensus guidelines recommending the use of diagnostic imaging\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n            \u003Cp id=\u0022p-8\u0022\u003EChanges in practice patterns, such as more aggressive treatment of elderly patients\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n            \u003Cp id=\u0022p-9\u0022\u003EIncreasing availability of comprehensive health care coverage\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-10\u0022\u003EDespite the increased utilization of imaging services, cardiac imaging is poorly supported by clinical evidence in many cases. For instance, current guidelines for identifying candidates for cardiac catheterization recommend risk assessment and noninvasive testing. However, precatheterization imaging studies provide little guidance on the optimal management of patients with high-risk ischemia. In a study of 398,978 patients in the American College of Cardiology National Cardiovascular Data Registry, 83.9% underwent noninvasive testing prior to elective catheterization [Patel MR et al. \u003Cem\u003EN Eng J Med\u003C\/em\u003E 2010]. Among patients without known disease, noninvasive testing was able to identify obstructive coronary artery disease (CAD) in only 37.6%. In addition, more than half (59%) of patients with positive stress test results had no obstructive CAD upon assessment with invasive angiography. Thus, in this large patient registry, cardiac imaging was a poor tool for identifying optimal candidates for catheterization and revascularization.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EBetter approaches to risk assessment may improve the lives of more than 12 million patients who undergo stress imaging each year, Dr. Shaw said. The National Heart, Lung, and Blood Institute (NHLBI) has developed a strategic plan for shaping the future of CV imaging research. According to the NHLBI, new clinical studies are needed to identify ways to reduce the inappropriate use of diagnostic tests and treatments. Studies are also needed to evaluate the risks, benefits, and costs of diagnostic tests and treatments in real-world patients and clinical settings. In addition, the NHLBI urges the cardiology community to incorporate diagnostic imaging techniques into future evidence-based guidelines on the prevention, diagnosis, and treatment of cardiovascular diseases (CVD).\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EFuture of Cardiac Imaging\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ERaymond J. Gibbons, MD, Mayo Clinic, Rochester, Minnesota, USA, outlined future opportunities in cardiac imaging. First, Dr. Gibbons encouraged cardiologists to be strict about applying only evidence-based approaches to cardiac imaging. In many clinical situations, the current evidence does not support the routine use of imaging studies, he said. For instance, the Predictors of Response to CRT (PROSPECT) trial revealed major technical and interpretive gaps that hinder the uniform application of imaging guidelines in daily clinical practice. The PROSPECT trial found that no single echocardiographic measure of dysynchrony reliably predicted response to cardiac resynchronization therapy (CRT), in part due to high levels of variability in echocardiographic findings [Chung ES et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008]. As an example, the interobserver variability in interpreting septal-to-posterior wall motion delay during echocardiography was 72.1%. According to the PROSPECT investigators, limiting the variability in measurements is a necessary step toward improving the predictive power of common cardiac imaging studies.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe utility of imaging modalities, such as adenosinestress radionuclide myocardial perfusion imaging (MPI), is also limited for identifying early CV risk in some patient groups. In the Detection of Ischemia in Asymptomatic Diabetics (DIAD) trial, screening for inducible myocardial ischemia with MPI did not reduce cardiac event rates among patients with diabetes [Young LH et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2009]. After 4.8 years, 2.7% of patients who underwent MPI screening and 3.0% of patients who were not screened developed cardiac events, including nonfatal myocardial infarction (MI) and cardiac death (p=0.73; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Therefore, the DIAD investigators concluded that current MPI techniques do not provide enough information about ischemic risk to justify widespread screening of asymptomatic diabetic patients.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/10\/24\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022DIAD: Cardiac Event Rates With and Without Screening for Myocardial Ischemia.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1371372517\u0022 data-figure-caption=\u0022DIAD: Cardiac Event Rates With and Without Screening for Myocardial Ischemia.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/10\/24\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/10\/24\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/10\/24\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11396\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EDIAD: Cardiac Event Rates With and Without Screening for Myocardial Ischemia.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECopyright \u00a9 2009 American Medical Association. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ERegarding the safety of current imaging tests, Dr. Gibbons recommended that clinicians balance the small risk of diagnostic radiation exposure against the potential benefit of cardiac imaging. In a recent study, Gerber and colleagues examined the lifetime cancer risk that was associated with various levels of radiation exposure [Gerber TC et al. \u003Cem\u003EJACC Cardiovasc Imaging\u003C\/em\u003E 2010]. For instance, among women aged 40 to 80 years, the overall risk of cancer increases substantially with increasing age.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EBy comparison, annual exposure to myocardial imaging with sestamibi 25 mCi over 4 decades increases lifetime cancer risk only negligibly, suggesting that annual diagnostic radiation exposure is relatively safe. Indeed, exposure to background environmental radiation levels, which measure approximately 3 mSv per year, carries a higher potential risk of malignancy than annual sestamibi exposure (25 mCi) [Gerber TC et al. \u003Cem\u003EJACC Cardiovasc Imaging\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003ELastly, Dr. Gibbons emphasized the importance of applying appropriateness criteria to imaging studies, such as single-photon emission computed tomography (SPECT) MPI. In a retrospective review of stress testing indications in one medical center, 14% of stress SPECT MPI studies and 18% of stress echocardiography studies were performed for inappropriate reasons [Carryer DJ et al. \u003Cem\u003EAm Heart J\u003C\/em\u003E 2010]. Updated appropriateness criteria from the American College of Cardiology Foundation and the American Society of Nuclear Cardiology provide important guidance on the use of SPECT MPI and other imaging studies in the clinical setting [Gibbons RJ et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EIn summary, Dr. Gibbons urged the cardiology community to develop new clinical evidence that clarifies the optimal use of various cardiac imaging modalities in patients with CAD. New technologies should keep patient radiation exposure as low as possible, and cardiologists should use imaging only when the potential benefit outweighs the potential for risk. To improve the quality of cardiac care, medical centers should also strive toward reducing the inappropriate use of imaging studies, Dr. Gibbons said.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/10\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmnfd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmnfd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}