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CLINICAL REVIEW: Sanjay K Prasad, Ravi G Assomull, and Dudley J Pennell Recent developments in non-invasive cardiology BMJ 2004; 329: 1386-1389 [Full text]

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Recent developments in non-invasive cardiology: Surely CT coronary angiography has been underplayed

Gareth J Morgan-Hughes, Nathan Manghat, Carl Roobottom, Andrew J Marshall   (16 December 2004)

Recent developments in non-invasive assessment of mitral regurgitation

Faisal F. Syed, Simon G. Ray, Bernard D. Prendergast   (16 December 2004)

Recent Advances in Echocardiography are important and clinically relevant

Abdullah A Mohammed   (18 December 2004)

Non-invasive cardiology

John Chambers, Kevin Fox (President-Elect BSE), Alan Fraser (President EAE), Petros Nihoyannopoulos (President-Elect EAE), Harald Becher (Oxford), Mark Monaghan (King's London), David Northridge (Edinburgh), Roxy Senior (Northwick Park)   (24 December 2004)

Recent developments in non-invasive cardiology

DENIS PELLERIN, Professor William J McKenna, Clinical Director at The Heart Hospital   (21 January 2005)

MRI Scans for imaging in Cardiology

Mahmood Ahmad, Noreen Khan, Ambreen Khan, Mahboob Ahmad Rehan, Irfan Qazi, Rizwan Mahmood   (16 January 2007)

Recent developments in non-invasive cardiology: Surely CT coronary angiography has been underplayed 16 December 2004
Gareth J Morgan-Hughes, Cardiology SpR Plymouth NHS Trust, PL6 8DH, Nathan Manghat, Carl Roobottom, Andrew J Marshall Send response to journal: Re: Recent developments in non-invasive cardiology: Surely CT coronary angiography has been underplayed	EDITOR – Despite the title, Sanjay Prasad and co-authors do not actually discuss the recent developments in cardiac computed tomography (CT).(1) Surely multi-detector CT coronary angiography is one of the most impressive advances in non-invasive cardiology for many years.(2)(3)(4) The authors’ judgement on the relative merits of the currently available non-invasive cardiac imaging modalities is perhaps questionable. Our colleagues in Germany and the United States of America would not agree that magnetic resonance coronary angiography has ‘similar results’ to CT coronary angiography. The markedly inferior spatial resolution of magnetic resonance imaging, in comparison to multi-detector CT, would prevent most authorities on non-invasive coronary artery imaging from making such a statement. The fact of the matter is that we are way behind the rest of the world in this field. Patients in Germany are already undergoing cardiac surgery with the surgeon guided by a CT coronary angiogram. There is no doubt that multi-detector CT will have, and in some UK centres already does have, a useful clinical role for non-invasive coronary angiography. This is certainly the case in our own institution, where we have succeeding in confirming that CT coronary angiography can be highly accurate at demonstrating the presence or absence of significant coronary artery disease.(5) Within six months 64 row multi-detector cardiac CT capable of imaging the whole heart in less than ten seconds, and offering sub-millimetre isotropic resolution, will be available in the UK. The sooner UK cardiologists and radiologists become aware of this technology and learn how best to use it, the better. It is new, it is different, and we should embrace it. References (1) Prasad S, Assomull R, Pennell D. Recent developments in non- invasive cardiology. BMJ 2004, 329:1386-1389. (2) Nieman K, Cademartiri F, Lemos P, Raaijmakers R, Pattynama P, de Feyter P. Reliable non-invasive coronary angiography with fast submillimetre multislice spiral computed tomography. Circulation 2002;106:2051-2054. (3) Ropers D, Baum U, Pohle K et al. Detection of coronary artery stenosis with thin-slice multi-detector row spiral computed tomography and multiplanar reconstruction. Circulation 2003;107:664-666. (4) Kuettner A, Trabold T, Schroeder S et al. Noninvasive detection of coronary lesions using 16-detector multislice spiral computed tomography technology: initial clinical results. J Am Coll Cardiol 2004;44:1230-1237. (5) Morgan-Hughes G, Roobottom C, Owens P, Marshall A. Highly accurate coronary angiography with sub-millimetre 16 slice computed tomography. Heart (in press early 2005) Competing interests: None declared
Recent developments in non-invasive assessment of mitral regurgitation 16 December 2004
Faisal F. Syed, Senior House Officer Department of Cardiology, Wythenshawe Hospital, Southmoore Road, Wythenshawe, M23 9LT, Simon G. Ray, Bernard D. Prendergast Send response to journal: Re: Recent developments in non-invasive assessment of mitral regurgitation	EDITOR – We read Prasad et al’s review [1] of developments in non- invasive cardiology with interest. Recent developments in the non- invasive assessment of mitral regurgitation (MR) merit further discussion. Though early surgery is increasingly recommended in degenerative MR to prevent irreversible decline in left ventricular (LV) function, its timing is notoriously difficult. Current international guidelines advocate serial echocardiographic estimation and referral for surgery when LV ejection fraction falls below 60% or end systolic diameter exceeds 45mm.[2] This approach has inherent limitations since ejection fraction is often maintained in the presence of LV dysfunction and most sudden deaths occur in asymptomatic patients with normal LV function. Echocardiography itself has intrinsic disadvantages, often overestimating MR and having technical demand with high interuser variability, particularly in the detection of the subtle early changes of LV impairment. Tissue Doppler parameters have been recently shown to predict very early postoperative decline in left ventricular function with greater sensitivity than standard echocardiography.[3] However, impact on long term clinical outcome is as yet unknown and this remains a highly specialised investigation requiring considerable expertise that is not routinely available. Plasma levels of brain natriuretic peptide (BNP) facilitate the diagnosis and management of heart failure and may also offer a more practical means of assessing early ventricular dysfunction in patients with valve disease. Levels of BNP in MR have been shown to correlate with symptomatic status [4,5] and the severity of MR in patients with preserved LV function.[5] Our own unpublished observations have confirmed these findings and also demonstrate a strong correlation between baseline BNP levels and ejection fraction prior to mitral valve repair and at 6 and 12 months follow-up. Large-scale prospective follow-up data addressing the impact of surgical intervention are now required to validate these early findings. If confirmed, we anticipate the inclusion of BNP measurement as an essential adjunct in the assessment of MR, particularly in those patients with minimal or no symptoms. This addition to protocols of assessment at minimal extra cost (20-25 Euros per assay) will allow earliest detection of LV dysfunction and complement the essential anatomical detail already provided by echocardiography. Faisal F. Syed, Senior House Officer Simon G. Ray, Consultant Cardiologist Bernard D. Prendergast, Consultant Cardiologist Department of Cardiology, Wythenshawe Hospital, Southmoor Road, Wythenshawe. M23 9LT Correspondence to Bernard.Prendergast@smuht.nwest.nhs.uk References 1. Prasad SK, Assomull RG, Pennell DJ. Recent developments in non- invasive cardiology. BMJ 2004;329:1386-1389. 2. Enriquez-Sarano M. Timing of mitral valve surgery. Heart 2002;87:79-85. 3. Agricola E, Galderisi M, Oppizzi M, Schinkel AF, Maisano F, De Bonis M, Margonato A, Maseri A, Alfieri O. Pulsed tissue Doppler imaging detects early myocardial dysfunction in asymptomatic patients with severe mitral regurgitation. Heart 2004;90:406-410. 4. Brookes CI, Kemp MW, Hooper J, Oldershaw PJ, Moat NE. Plasma brain natriuretic peptide concentration in patients with chronic mitral regurgitation. J Heart Valve Dis 1997;6:608-612. 5. Sutton TM, Stewart RA, Gerber IL, West TM, Richards AM, Yandle TG, Kerr AJ. Plasma natriuretic peptide levels increase with symptoms and severity of mitral regurgitation. J Am Coll Cardiol 2003;41:2280-2287. Competing interests: None declared
Recent Advances in Echocardiography are important and clinically relevant 18 December 2004
Abdullah A Mohammed, Clinical Research Fellow Cardiology Department , Cardiothoracic Unit, Northern General Hospital, Sheffield S5 7AU Send response to journal: Re: Recent Advances in Echocardiography are important and clinically relevant	Editor, The clinical review by Prasad et al. (BMJ issue 11December) on recent advances in non-invasive cardiology [1] highlights an exciting era in the rapid development of cardiac assessment especially that of cardiac imaging. Although the stated remit for the article is to ‘discuss important developments in non-invasive cardiology especially that have recently come into clinical use’ the article makes little mention of recent advances in echocardiography, which is the most accessible and clinically applicable mode of cardiac imaging. I believe it is important to update clinicians on recent advances in echocardiography and to put it in clinical context with the other cardiac imaging techniques mentioned in the article. While MRI and nuclear myocardial perfusing imaging for example are expensive and limited to a few centres echocardiography is widely available to the majority of all hospitals including small District General Hospitals and requires little extra cost in manpower as it is part of the cardiology training. Furthermore, echocardiography is an essential part of the structural and functional assessment of a wide variety of clinical cardiac conditions which makes both current and new advances in its applications of interest to many physicians including general practitioners as they have increasingly open access service they are able to utilise in assessing their patients before referral to a cardiologist. New development in echocardiography includes stress, contrast, three- dimensional, tissue Doppler and portable echocardiography many of which are increasingly applied in clinical practice beyond research. It is recognized for example that stress echocardiography has similar sensitivity and specificity to nuclear myocardial perfusing imaging in the diagnosis of coronary artery disease, assessment of myocardial viability and the prognostic assessment for ischaemic heart disease [2]. Contrast echocardiography adds to the diagnostic accuracy of stress echocardiography by obtaining better image quality especially in patients difficult to image such as obese patients or patients with lung disease. In addition recent advances with contrast agents allow myocardial perfusing imaging in addition to enhanced endocardial border delineation and hence allows more comprehensive assessment of myocardial function, ischaemia and viability [3]. Three-dimensional echocardiography[4] both transthoracic and transoesophageal have emerging roles in the accurate assessment of left ventricular structure and function with applications including congenital heart disease, valvular heart disease and intracardiac masses. These applications are of potential great value in planning and monitoring surgical interventions. Tissue Doppler imaging is now used in many clinical setting including the assessment of diastolic heart failure, left ventricular filling pressures and interestingly in the evaluation of subclinical left ventricular dysfunction with many relevant clinical applications. (see table) , Advances in microscopic technology have allowed a hand held echocardiography machine to be available for clinical use at the bedside with potential benefit of immediate diagnosis and treatment especially in the acutely ill patients [6]. The table below summarises recent advances in echocardiography and their clinical applications. References are provided for further reading. Echocardiography modality & Clinical applications ------------------------------------------------ Stress Echocardiography : -CAD diagnosis -Risk stratification -Myocardial viability (hibernation) assessment Contrast Echocardiography: -Improved combined assessment of LV function, ischaemia , viability. Tissue Doppler Echocardiography: -Subclinical systolic dysfunction assessment eg regurgitant valve lesions, early detection of hypertrophyic cardiomypathy, Cardiac hereditary diseases eg Friedrich’s ataxia. -Diastolic heart failure assessment. -Myocardial systolic synchrony assessment as a guide to biventricular pacemaker implantation in heart failure. Three-dimensional Echocardiography: -Congenital heart disease eg septal defects -Valvular lesions assessment. Portable Echocardiography: -Acute: Left ventricular dysfunction, pericardial effusion. -Outpatient: to assess Obstructive valve lesion prior to ischaemic stress tests. References 1.Sanjay K Prasad, Ravi G Assomull, and Dudley J Pennell Rcent developments in non-invasive cardiology BMJ 2004; 329: 1386-1389 [Full text] 2.Marwick T H. Stress echocardiography. Heart 2003; 89:113–8.[Free Full Text] 3.Mulvagh S L et al. Contrast echocariography: current and future applications. J Am Soc Echocardiogr 2000; 13:331–42.[CrossRef][Medline] 4.L Sugeng, L Weinert and R M Lang Left ventricular assessment using real time three dimensional echocardiography.Heart 2003;89:iii29 5.Marwick T H Clinical applications of tissue Doppler imaging: a promise fulfilled Heart 2003 89: 1377-1378 6.Spencer KT, Anderson AS, Bhargava A, Bales AC, Sorrentino M, Furlong K, et al. Physician-performed point-of-care echocardiography using a laptop platform compared with physical examination in the cardiovascular patient. J Am Coll Cardiol 2001;37: 2013-8.[CrossRef][ISI][Medline] Competing interests: None declared
Non-invasive cardiology 24 December 2004
John Chambers, President of British Society of Echocardiography St Thomas Hospital, Kevin Fox (President-Elect BSE), Alan Fraser (President EAE), Petros Nihoyannopoulos (President-Elect EAE), Harald Becher (Oxford), Mark Monaghan (King's London), David Northridge (Edinburgh), Roxy Senior (Northwick Park) Send response to journal: Re: Non-invasive cardiology	Editor The recent review of advances in noninvasive cardiology (1) fails to discuss echocardiography except briefly as an electronic addendum. What you have published is a very selective review, mainly about cardiovascular magnetic resonance and other tomographic techniques. In addition to contrast echocardiography and tissue Doppler, there have been many other technical developments, of which 3D echocardiography (3) is a striking omission from the review. 3D imaging has advantages over 2D for the assessment of left ventricular volumes and synchrony, for congenital disease, the anatomy of the mitral valve and for the morphology of regurgitant jets. It is likely to become part of the repertoire of every specialist department. Another advance, the miniaturisation of echocardiography machines, now allows studies to be performed anywhere, including a ward round or at the patient’s home (4). Miniaturisation, and the influence of national programmes like the NICE document on heart failure, has allowed echocardiography to spread outside the cardiac department. It is increasingly being adopted by general practitioners, accident and emergency physicians and specialists in acute medicine who are able to capitalise on the portability of the technique. Technical advances and clinical developments also combine to explain the growth of stress echocardiography which could be applied to 3.8 per 1000 population per year in the UK (2). The technique has repeatedly been validated for the prediction of coronary stenoses and for stratifying risk (5). A fuller account of these and other advances in echocardiography is already available (6). There should be no competition between different imaging modalities. The most appropriate option should be used for any particular clinical indication. Currently, cardiovascular magnetic resonance is the most accurate method for the non-invasive measurement of left ventricular volumes and mass (although 3-dimensional echocardiography is almost as precise), but it is the preferred investigation for these indications mainly in research studies. It is also clinically useful for assessing chronic stable aortic disease. However, for the detailed assessment of left ventricular function, and for the diagnosis and quantification of heart valve disease, echocardiography remains the investigation of choice. Echocardiography will always remain essential for the investigation of acutely ill patients since it is portable. Echocardiography is also the most widely-available non-invasive cardiac imaging technique. Most district hospitals perform 3000 – 5000 studies each year equating to about 1.5 million studies each year throughout the UK. National workforce planning suggest the need for 11 – 15 echocardiography consultants per million population compared with 2.9 per million for nuclear medicine and 1 per million for developing specialties including magnetic resonance and cardiac CT (2). We are concerned that this article could lead health service managers to eschew the relatively inexpensive, effective, safe and widely available echocardiographic techniques for the apparently more alluring, and certainly more expensive techniques of magnetic resonance and cardiac CT. All have developing roles either in clinical practice or research and it is important that they are viewed in proper perspective. Competing interests: None declared
Recent developments in non-invasive cardiology 21 January 2005
DENIS PELLERIN, Consultant Cardiologist, Director of echocardiography The Heart Hospital, London W1G 8PH, Professor William J McKenna, Clinical Director at The Heart Hospital Send response to journal: Re: Recent developments in non-invasive cardiology	You published a Clinical Review in the 11/12/2004 issue of the Journal entitled Recent developments in non-invasive cardiology by SK Prasad, RG Assomull and DJ Pennell. This excellent review focused on cardiac MRI and nuclear imaging. However, there are very few dedicated cardiac MRI units in the UK and most cardiology departments do not have access to cardiac MRI. In contrast, Echocardiography is widely available, easy to use, and cost effective. All patients with heart disease have an echo study which has a crucial role in the decision making process. Although this review was entitled Recent developments in non-invasive Cardiology, Echocardiography was not included into this review. The true potential of this ultrasound imaging technique is now revealed with the development of new concepts and new imaging modalities. Major improvement in image quality has been obtained with harmonic imaging, which can be used during all standard examinations. New concepts in blood flow analysis have been developed for the quantification of valve disease. Aortic stenosis is quantified by aortic valve area using the concept of continuity of flow. Mitral and aortic regurgitations are objectively assessed by effective regurgitant orifice area and regurgitant volume using the concept of proximal isovelocity surface area. This information cannot be reliably and routinely obtained with other imaging modalities. New ultrasound imaging modalities have been developed for the assessment of regional myocardial wall motions and reduction of inter and intra observer variability. Regardless of image quality and imaging technique, regional wall motion analysis has been subjective, visually assessed and at best semi quantitative. Adequate training to distinguish between segmental thickening and passive motion due to heart translation or tethering by adjacent normal segments was mandatory. Endocardial border and wall thickening can be optimally visualized in all myocardial segments by contrast cavity opacification. Quantification of segmental ventricular wall motions reduces the expertise needed for interpretation and improves reproducibility for detection of heart disease. New imaging modalities include parametric imaging (tissue Doppler, strain and strain rate imaging), integrated backscatter, myocardial contrast echocardiography and 3D echocardiography. They are available during transthoracic and transoesophageal examinations. Combination of new imaging modalities can be performed at rest and during stress to improve diagnostic, guide therapy and stratify risk for example 3D with contrast, 3D with tissue synchronisation derived tissue Doppler, stress echo with contrast, and stress echo with tissue Doppler. These modalities are used to detect myocardial ischaemia, identify myocardial viability in patients with chronic coronary artery disease and severe left ventricular dysfunction, improve early detection of patients with hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia, and selection of patients with severe heart failure before biventricular device implantation. Technical progresses in ultrasound cardiac imaging have markedly improved patient management with cost reduction. With regards Yours sincerely Competing interests: None declared
MRI Scans for imaging in Cardiology 16 January 2007
Mahmood Ahmad, CTF-HO Medway Maritime Hospital,Windmill Road, Gillingham, Kent. ME7 5NY, Noreen Khan, Ambreen Khan, Mahboob Ahmad Rehan, Irfan Qazi, Rizwan Mahmood Send response to journal: Re: MRI Scans for imaging in Cardiology	I would agree with the review that newer developments in non-invasive Cardiology especially MRI and CT Scans of the heart provide deeper imaging methods than what was available in the past. Recent studies have shown that Reversible myocardial dysfunction can be identified by contrast-enhanced MRI and can be used to predict whether regions of abnormal ventricular contraction will improve after revascularization in patients with coronary artery disease. (1) The transmural extent of hyperenhancement at Contrast (Gandolinium) enhanced MRI has been related to improvement of function in reperfused MI. (2) In severe ischemic heart failure, MRI hyperenhancement as a marker of myocardial scar closely agrees with PET data seems to identify scar tissue more frequently than PET, possibly because of the higher resolution of MRI Scans and without the radiation exposure (3) In patients with unexplained repolarisation abnormalities, a normal routine echocardiogram without contrast cannot exclude apical HCM and the the apical HCM found on MRI scans can have wall thickness up to 28 mm.(4) Hopefully the cost-effectiveness of these methods will improve over time allowing more widespread use. (1)J Am Coll Cardiol. 2003 Sep 3;42(5):902-4. Delayed contrast-enhanced magnetic resonance imaging for the prediction of regional functional improvement after acute myocardial infarction. Beek AM, Kuhl HP, Bondarenko O, Twisk JW, Hofman MB, van Dockum WG, Visser CA, van Rossum AC. (2)N Engl J Med. 2000 Nov 16;343(20):1488-90. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, Klocke FJ, Bonow RO, Judd RM. (3).Circulation. 2002 Jan 15;105(2):162-7. Assessment of myocardial viability with contrast-enhanced magnetic resonance imaging: comparison with positron emission tomography. Klein C, Nekolla SG, Bengel FM, Momose M, Sammer A, Haas F, Schnackenburg B, Delius W, Mudra H, Wolfram D, Schwaiger M. (4) Heart. 2004 Jun;90(6):645-9. Detection of apical hypertrophic cardiomyopathy by cardiovascular magnetic resonance in patients with non-diagnostic echocardiography. Moon JC, Fisher NG, McKenna WJ, Pennell DJ. Competing interests: None declared