Routine Non-invasive Testing Research Articles

Comprehensive genome-wide analysis of routine non-invasive test data allows cancer prediction: A single-center retrospective analysis of over 85,000 pregnancies.

BackgroundImplausible false positive results in non-invasive prenatal testing (NIPT) have been occasionally associated with the detection of occult maternal malignancies. Hence, there is a need for approaches allowing accurate prediction of whether the NIPT result is pointing to an underlying malignancy, as well as for organized programs ensuring efficient downstream clinical management of these cases.MethodsUsing a data set of 88,294 NIPT performed at University Hospital Leuven (Belgium) between November 2013 and March 2020, we retrospectively evaluated the positive predictive value (PPV) of our NIPT approach for cancer detection. In this approach, whole-genome cell-free DNA (cfDNA) data from NIPT were scrutinized for the presence of (sub)chromosomal copy number alterations (CNAs) predictive for a malignancy, using an unbiased NIPT analysis pipeline coined GIPSeq. For suspected cases, the presence of a maternal cancer was evaluated via subsequent multidisciplinary clinical follow-up examinations. The cancer-specificity of the identified CNAs in cfDNA was assessed through genetic analyses of a tumor biopsy.FindingsFifteen women without a cancer history were identified with a GIPSeq result suggestive of a malignant process. Their cfDNA profiles showed either genome-wide aberrations or a single trisomy 8. Upon clinical examinations, a solid or hematological cancer was identified in 4 and 7 cases, respectively. Three women were identified as having a clonal mosaicism. For one case no underlying condition was found. These numbers add to a PPV of 73%. Based on this experience, we presented a multidisciplinary care path for efficient clinical management of these cases.InterpretationThe presented approach for analysing NIPT results has a high PPV, yet unknown sensitivity, for detecting asymptomatic malignancies upon routine NIPT. Given the complexity of diagnosing a pregnant woman with cancer, clinical follow-up should occur in a well-designed multidisciplinary setting, such as via the care model that we presented here.FundingThis work was supported by Research Foundation Flanders and KU Leuven funding.

Routine saliva testing for the identification of silent coronavirus disease 2019 (COVID-19) in healthcare workers.

Current COVID-19 guidelines recommend symptom-based screening and regular nasopharyngeal (NP) testing for healthcare personnel in high-risk settings. We sought to estimate case detection percentages with various routine NP and saliva testing frequencies. Simulation modeling study. We constructed a sensitivity function based on the average infectiousness profile of symptomatic coronavirus disease 2019 (COVID-19) cases to determine the probability of being identified at the time of testing. This function was fitted to reported data on the percent positivity of symptomatic COVID-19 patients using NP testing. We then simulated a routine testing program with different NP and saliva testing frequencies to determine case detection percentages during the infectious period, as well as the presymptomatic stage. Routine biweekly NP testing, once every 2 weeks, identified an average of 90.7% (SD, 0.18) of cases during the infectious period and 19.7% (SD, 0.98) during the presymptomatic stage. With a weekly NP testing frequency, the corresponding case detection percentages were 95.9% (SD, 0.18) and 32.9% (SD, 1.23), respectively. A 5-day saliva testing schedule had a similar case detection percentage as weekly NP testing during the infectious period, but identified ~10% more cases (mean, 42.5%; SD, 1.10) during the presymptomatic stage. Our findings highlight the utility of routine noninvasive saliva testing for frontline healthcare workers to protect vulnerable patient populations. A 5-day saliva testing schedule should be considered to help identify silent infections and prevent outbreaks in nursing homes and healthcare facilities.

Effectiveness of Ultrasound Measured Urinary Bladder Wall Thickness as a = Diagnostic and Follow up Tool in Men With Bladder Outlet Obstruction

Aim: The present study was undertaken with the aim to standardize ultrasound measured urinary bladder wall thickness (UMUBWT) as an additional routine noninvasive test to assess the bladder outflow obstruction (BOO) and to monitor the therapeutic effects of BOO in follow-up after surgical correction of obstruction. Methods: This is an interventional study (pretest-posttest type of clinical trial) conducted between December 2012 to May 2015 where sample size was 55 and sampling technique was purposive. In BOO patient transabdominal sonography was performed using a 7.5 MHz. probe. The thickness of the anterior bladder wall at the midline was measured in both preoperative and postoperative period ( three months after operation) at 3 points approximately 1 cm apart and the average value was recorded. Results: In this study age range was 21-73 years with mean±SD of age was 48.76±15.08 years. In BOO patient preoperative UMUBWT was 0.51 ± 0.16 cm and which reduced to 0.26 ± 0.05 cm three months after surgical correction of obstruction. Conclusion: UMUBWT is a noninvasive, cheap and easily available additional diagnostic tool for detecting BOO as well as it can measure the therapeutic effects in postoperative period. Bangladesh Journal of Urology, Vol. 22, No. 2, July 2019 p.188-193

Pragmatic trial comparing routine versus no routine functional testing in high-risk patients who underwent percutaneous coronary intervention: Rationale and design of POST-PCI trial

Although the need to detect restenosis has diminished in the contemporary practice of percutaneous coronary intervention (PCI) with drug-eluting stents (DES), the surveillance of ischemia owing to restenosis or disease progression deserves attention in high-risk PCI settings. It is unknown whether follow-up strategy of routine noninvasive functional testing potentially reduces the risk of major cardiovascular events in high-risk PCI patients. The POST-PCI study is an investigator-initiated, multicenter, prospective randomized trial comparing the effectiveness of two follow-up strategies in patients with high-risk anatomic or clinical characteristics who underwent PCI. Study participants were randomly assigned to either (1) the routine noninvasive stress testing (exercise electrocardiography, nuclear stress imaging, or stress echocardiography) at 12 months post-PCI or (2) the standard-care without routine testing. In the routine stress testing group, depending on the testing results, all clinical decisions regarding subsequent diagnostic or therapeutic procedures were at the treating physician's discretion. The primary endpoint was a composite outcome of death from any causes, myocardial infarction, or hospitalization for unstable angina at 2 years post-PCI. More than 1700 high-risk PCI patients have been randomized over 2.0 years at 11 major cardiac centers in Korea. This pragmatic POST-PCI trial will provide valuable clinical evidence on the effectiveness of follow-up strategy of routine noninvasive stress testing in high-risk PCI patients.

Copy number-based quantification assay for non-invasive detection of PVT1-derived transcripts.

BackgroundOne of the most important susceptibility loci for cancer is the 8q24 human chromosomal region. The non-protein coding gene locus plasmacytoma variant translocation 1 (PVT1) is located at 8q24 and is dysregulated in prostate cancer. PVT1 gives rise to multiple transcripts which may have different functions. Here, we describe a real-time quantitative polymerase chain reaction (qPCR)-based assay for copy number-based quantitation of PVT1 exons 4A, 4B, and 9 to enable accurate, reproducible, and quantifiable detection.MethodsPVT1 exons 4A, 4B, and 9 were cloned into a plasmid vector to create standards for subsequent creation of linear standard curves representing a broad range of concentrations. PCR was carried out using SYBR-Green signal detection to quantify PVT1 exons 4A, 4B, and 9. The efficacy of this assay was evaluated by using it to detect these transcripts in prostate epithelial and prostate cancer cell lines, normal and cancerous human prostate tissues, human serum, mouse plasma, and urine samples.ResultsThe results indicate that the assay can be used to quantify both low and high copy numbers of PVT1-derived transcripts. This is the first report of a copy number-based quantification assay for non-invasive detection of PVT1 derived transcripts.ConclusionsThis novel assay holds promise for routine non-invasive testing in diseases where PVT1 is dysregulated.

Recommendations for conducting invasive urodynamics for men with lower urinary tract symptoms: Qualitative interview findings from a large randomized controlled trial (UPSTREAM)

AimsTo capture in‐depth qualitative evidence regarding attitudes to and experiences of urodynamic testing among men with lower urinary tract symptoms (LUTS) at each end of the clinical pathway.MethodsSemi‐structured interview study conducted within the Urodynamics for Prostate Surgery: Randomized Evaluation of Assessment Methods (UPSTREAM) trial, which randomized men to a care pathway including urodynamics or routine non‐invasive tests from 26 secondary care urology sites across England. Men were interviewed after assessments but prior to treatment, or after surgery for LUTS. Men were purposively sampled to include those who had urodynamics and those who did not, and diversity in demographic characteristics and symptom burden. Interviews were analyzed using inductive thematic analysis.ResultsForty‐one men participated (25 pre‐treatment, 16 post‐surgery), ages 52‐89. The 16 men who had not previously experienced urodynamics said they would accept the test in their assessment, but some were apprehensive or wanted more information. The 25 men who had experienced urodynamics all found it acceptable, though some reported pain, infection, or embarrassment. Embarrassment was minimized by informing patients what the procedure would be like, and ensuring privacy. Urodynamics was valued for its perceived diagnostic insight. Information deficits were reported before, during, and after the test. How and when results were explained and the adequacy of explanations varied.ConclusionsUrodynamics is acceptable to men with LUTS and generally well‐tolerated. To ensure patients are prepared and informed, good communication before and during the procedure is essential. Privacy should be prioritized, and test results discussed promptly and in sufficient detail. Staff require training and guidance in these areas.

Incidence of X and Y Chromosomal Aneuploidy in a Large Child Bearing Population.

BackgroundX&Y chromosomal aneuploidies are among the most common human whole-chromosomal copy number changes, but the population-based incidence and prevalence in the child-bearing population is unclear.MethodsThis retrospective analysis of prospectively collected data leveraged a routine non-invasive prenatal test (NIPT) using parental genotyping to estimate the population-based incidence of X&Y chromosome variations in this population referred for NIPT (generally due to advanced maternal age).ResultsFrom 141,916 women and 29,336 men, 119 X&Y chromosomal abnormalities (prevalence: 1 in 1,439) were identified. Maternal findings include: 43 cases of 45,X (40 mosaic); 30 cases of 47,XXX (12 mosaic); 3 cases of 46,XX uniparental disomy; 2 cases of 46,XY/46,XX; 23 cases of mosaicism of unknown type; 2 cases of 47,XX,i(X)(q10). Paternal findings include: 2 cases of 47,XXY (1 mosaic); 10 cases of 47,XYY (1 mosaic); 4 partial Y deletions.ConclusionsSingle chromosome aneuploidy was present in one of every 1,439 individuals considered in this study, showing 47,XXX; 47,XX,i(X)(q10); 47,XYY; 47,XXY, partial Y deletions, and a high level of mosaicism for 45,X. This expands significantly our understanding of X&Y chromosomal variations and fertility issues, and is critical for families and adults affected by these disorders. This current and extensive information on fertility will be beneficial for genetic counseling on prenatal diagnoses as well as for newly diagnosed postnatal cases.

371 - High Output Heart Failure—A Reversible Cause Missed Again!

Introduction: High output heart failure is a rare but often reversible condition in adults. Current guidelines do not suggest screening for high output in heart failure patients unless it is suggested by history or physical exam. We describe here an unusual case of heart failure secondary to renal A-V malformation discovered incidentally. Case Presentation: A 74 year old woman with hypertension, hyperlipidemia, and chronic systolic heart failure due to nonischemic cardiomyopathy diagnosed over a year ago presented with acute exacerbation to the emergency department. Her echocardiogram revealed dilated cardiomyopathy with ejection fraction of 30%. During work up for her abdominal pain at this hospitalization, an ultrasound and a CT scan revealed an incidental large cavernous right renal arteriovenous malformation with a dilated right renal artery (2.3 cm) feeding into a nidus of vessels. Right heart catheterization revealed cardiac output of 8.3 L/min. In absence of any other reason for her high output heart failure, vascular surgery was consulted and the renal A-V malformation was successfully embolized. Three months later, the patient was seen at a follow up visit with complete resolution of her symptoms. At that visit, the echocardiogram revealed normalization of EF (55–60%) and chamber sizes. Cardiac output measured by echocardiography was 5.2 L/min. Discussion: Over 25% of heart failure patients have idiopathic cardiomyopathy. Attempts to find a reversible cause are vital as otherwise the prognosis is poor with high morbidity and mortality. Cardiac output can be measured noninvasively during a routine echocardiography, avoiding need for an invasive test such as cardiac catheterization. In cases of idiopathic cardiomyopathy leading to heart failure, detecting high output through a noninvasive test may lead to establishment of a reversible cause. Some of the causes of high output heart failure are A-V fistulas, anemia, hyperthyroidism, and sepsis. Beriberi can also cause high output heart failure but it is rare in adults in developed countries. Echocardiography can help not only in diagnosis but also in follow up after treatment to monitor change in cardiac output. Thus a routine noninvasive test, if used properly, could provide significant information that can alter the course of the patient's disease. Conclusion: In cases of idiopathic heart failure, measuring cardiac output through echocardiography is safe and inexpensive. Detection of high cardiac output should ignite the search for a potentially reversible etiology. Echocardiography can also be used to monitor efficacy of treatment.

Non-invasive, serum DNA pregnancy testing leading to incidental discovery of cancer: A good thing?

Cell-free DNA for perinatal screening is a growing industry. Non-invasive prenatal testing (NIPT) is based on the premise that foetal DNA is able to cross the placental barrier and enter the mother’s circulation, where it can be examined for chromosomal abnormalities, such as trisomy 13, 18 or 21. Such tests are expected to be widely used by pregnant women, with the annual market expected to surpass $1 billion.Recently, a number of case reports have emerged in the haematology-oncology literature. The routine use of NIPT has led to the discovery of maternal neoplasms. Most writers have concluded that this is yet another benefit of the test; however, a closer examination of the cases reveals that this incidental detection may not improve patient outcomes. In some cases, early detection provides lead time bias, but does not change the ultimate clinical outcome, and in other cases, detection constitutes earlier knowledge of a cancer whose natural history cannot be altered. Here, we explore in detail cases where cancer was incidentally discovered among women undergoing routine non-invasive pregnancy testing, and investigate whether or not these women were benefitted by the discovery.

High Prevalence of Neutrophil Cytoplasmic Autoantibodies in Infants with Food Protein-Induced Proctitis/Proctocolitis: Autoimmunity Involvement?

Background. Food protein-induced proctitis/proctocolitis (FPIP) is the most common noninfectious colitis in children in the first year of life. Along with the overall clinical symptoms, diarrhoea and rectal bleeding are the main manifestations of the disease. There is no routine noninvasive test that would be specific for this type of colitis. The aim of our study was to find a noninvasive laboratory test or tests that may be helpful in differential diagnosis of food protein-induced proctitis/proctocolitis. Methods. ANA, ANCA, ASCA, a-EMA, a-tTg, specific IgE, total IgE, IgG, IgA, IgM, and concentration of serum calprotectin were measured in a group of 25 patients with colitis and 18 children with other diagnoses. Results. Atypical-pANCA antibodies of IgG isotype were detected in the sera of 24 patients by the method of indirect immunofluorescence, and 5 patients showed also the positivity of IgA isotype. In control samples these autoantibodies were not detected. Other autoantibodies were not demonstrated in either patient or control group. Conclusions. Of the parameters tested in noninfectious colitis, atypical-pANCA on ethanol-fixed granulocytes appears to be a suitable serological marker of food protein-induced proctitis/proctocolitis and suggests a possible involvement of an autoimmune mechanisms in the pathogenesis of this disease.

Correlation Between Computed Tomography Expression of Pulmonary Hypertension and Severity of Lung Disease in Cystic Fibrosis Patients

Pulmonary hypertension (PHTN) is a significant cause of morbidity and mortality in patients with cystic fibrosis (CF), but a routine noninvasive test for evaluating PHTN is lacking. We aimed to determine whether there is a correlation between computed tomography (CT) signs for PHTN and lung disease severity in CF. We retrospectively evaluated high-resolution CT studies of 91 consecutive CF patients. The ratios of the widest diameters of the main pulmonary artery (MPA), right pulmonary artery, and left pulmonary artery to the ascending aorta (Ao) were calculated. MPA/Ao>1 was considered indicative for PHTN. Lung severity was assessed with modified Brody scores for the left lung (LL), right lung (RL), and overall [Total Brody Score (TBS)]. The nonparametric Pearson χ test was performed for determining the correlation between Brody score and objective CT signs for PHTN. This study included 54 male and 37 female patients aged between 3 and 67 years (mean 17.6 y). Mean RL, LL, and TBS were 23.71, 23.31, and 47.15, respectively. Of the 91 patients, 28 (30.8%) had MPA/Ao>1, indicating a high probability for PHTN. Among these patients, the mean TBS was 38.8, as compared to mean of 50.8 in 63 patients with MPA/Ao≤1. No correlation was found for the RL and LL separately. There was no correlation between parenchymal lung disease severity assessed by the modified Brody score and CT signs of PHTN in CF patients.

Routine Noninvasive Testing and Highly Sensitive Troponin Immunoassays—Reply

Routine Noninvasive Testing and Highly Sensitive Troponin Immunoassays—Reply

Chest Pain in the Emergency Department

Current clinical practice for patients presenting to the emergency department with a resolved episode of chest pain and no electrographic or biomarker abnormalities is to conduct routine noninvasive testing, in accordance with American College of Cardiology and American Heart Association guidelines. The rationale is to further reduce the risk of missing a myocardial infarction, a major source of suits filed against emergency department physicians. Patients with negative stress test results may be reassured, with low event rates in the subsequent 30 days. Patients with positive stress test results have higher 30-day event rates, and a small fraction undergo revascularization procedures. Despite this endorsement, open questions remain. Does our current practice lead to the stenting of asymptomatic patients in the inevitable cases where the inciting pain was noncardiac? And, most importantly, does our practice improve outcomes? Randomized trials evaluating routine stress testing in other contexts have yielded negative results, despite diagnosing significant coronary artery disease. Population data suggest that our current practice may be increasing the diagnosis of coronary artery disease and the rate of intervention while failing to decrease rates of myocardial infarction. We propose that randomized trials be conducted to evaluate whether any testing is better than no further intervention. Data from such an evidence-based approach has the potential to reverse our current practice.

The Usefulness of Super-Selective Computed Tomography Angiography (CTA) for Diagnosing and Localizing a Small Insulinoma

Localization of insulinomas by preoperative imaging is critical for successful surgical resection. However, the visualization and localization of small insulinomas by recent imaging modalities still remains a challenge. Here, we report a 77-year-old woman with a small insulinoma successfully localized by performing arterial stimulation and venous sampling (ASVS), and subsequent super-selective CTA (SSCTA). It was not visualized by routine non-invasive imaging tests such as digital subtraction angiography (DSA). The small size (1.0 cm) of the surgically removed tumor supports the usefulness of SSCTA for localizing very small insulinomas.

Contrast‐Enhanced Power and Color Doppler Ultrasonography of the Pancreas in Healthy and Diseased Cats

The diagnosis of feline pancreatic disease is difficult, because clinical abnormalities and routine noninvasive diagnostic tests are unreliable. The purpose of this study was to investigate by Doppler ultrasonography if vascularity and blood volume differs in the otherwise ultrasonographically normal and diseased feline pancreas. Thirty-six client owned cats. The pancreas was examined with B-mode and contrast-enhanced color and power Doppler ultrasonography. Doppler images were analyzed with a computer program: parameter fractional area represents a vascularity index and color-weighted fractional area assesses blood volume. Based on the B-mode findings, the pancreas was considered normal in 11 clinically healthy cats and diseased in 25 cats of which 4 were clinically healthy and 21 had clinical signs consistent with pancreatic disease. Histologic or cytologic samples were taken in all diseased pancreata. Fifteen samples were of diagnostic quality: purulent or mixed cellular inflammation (8), nodular hyperplasia (4), and neoplasia (3) were identified. Vascularity and blood volume for all Doppler methods was significantly higher in cats with pancreatic disease. Significantly higher Doppler values were detected with power Doppler than with color Doppler, and with postcontrast color and power Doppler than with precontrast Doppler technologies. Contrast-enhanced Doppler ultrasonography appears feasible in the feline pancreas. Significant differences were found between normal cats and those with evidence of pancreatic pathology. Further studies are needed to evaluate its use for the differentiation of pancreatic disorders and in cats suspected to have pancreatic disease but without B-mode ultrasonographic changes of the pancreas.

Cost of routine screening for carotid and lower extremity occlusive disease in patients with abdominal aortic aneurysms

Objective: The burden of clinically relevant noncoronary atherosclerotic occlusive disease in patients with abdominal aortic aneurysms (AAAs) is poorly defined. Furthermore, the cost-effectiveness of routine versus selective preoperative noninvasive examination of the carotid and lower extremity arterial beds has not been established in patients who undergo elective AAA repair. Methods: Diagnostic vascular laboratory study results were reviewed in 206 patients who underwent evaluation before AAA repair from 1994 to 1998. The patients underwent routine preoperative carotid duplex scan examinations and lower extremity Doppler scan arterial studies with ankle-brachial index (ABI) determinations. The medical records were reviewed for the identification of clinical evidence consistent with cerebrovascular or lower extremity arterial occlusive disease. The costs of routine screening and selective screening were determined with Medicare reimbursement schedules. Results: The prevalence rate of advanced (80% to 100%) carotid artery stenosis (CAS) was 3.4%, and 18% of the patients had CAS between 60% and 100%. Advanced peripheral vascular occlusive disease (PVOD; ABI, <0.3) was found in 3% of the patients, and 12% of the patients had an ABI of less than 0.6. Most patients with advanced CAS (71%) or advanced PVOD (83%) had clinical indications of their disease. The absence of clinical evidence of disease had a negative predictive value of 99% for both advanced CAS and PVOD. The cost of routine screening for all patients for advanced CAS was $5445 per case. Routine screening for severe PVOD costs were $3732 per case discovered. In contrast, the costs for selective screening for advanced CAS or PVOD in patients with appropriate history or symptoms were $1258 and $785 per case found, respectively. Conclusion: Routine noninvasive diagnostic testing for the identification of asymptomatic CAS and PVOD in patients with AAA may not be justified. Preoperative screening is more clearly indicated for patients with AAAs who have clinical evidence suggestive of CAS or PVOD. (J Vasc Surg 2002;35:754-8.)

Utilidad de la aplicación de técnicas de modelado no lineal en el análisis de electrocardiogramas de pacientes con infección chagásica

The application of nonlinear techniques allows the definition of early risk markers in patients with Chagas infection and without any evidence of cardiac involvement evaluated by standard diagnostic test. Nonlinear modeling techniques have proved to be effective in cardiac rhythm analysis, thereby justifying its use in Chagas' disease. The routine noninvasive test and heart rate variability analysis were performed in Chagas' disease patients and in a group of healthy subjects. In a second phase we used nonlinear analysis in the evaluation of patients with Chagas infection and no evidence of heart disease, Chagasic patients with minimal electrocardiographic abnormalities and healthy controls. Twenty-four-hour electrocardiographic ambulatory monitoring and heart rate variability allowed us to establish differences between the healthy subjects and patients with Chagas infection without evidence of cardiac disease (p c 0.05 and p <0.005). In sharp contrast nonlinear analysis characterized 4 subgroups in Chagasic patients without cardiac involvement (sensitivity and specificity of 1 00%). Our findings suggest that nonlinear modeling techniques have a high sensitivity and specificity in the early detection of cardiac involvement and very early autonomic disturbance. We recommend that these techniques be applied to patients with high risk of cardiac disease other than Chagasic myocarditis. Our findings should be corroborated with studies in larger populations. We are currently developing a prospective study to this end.

Selective preoperative cardiac screening improves five-year survival in patients undergoing major vascular surgery: A cost-effectiveness analysis

Objective: To evaluate the long-term outcomes (5-year survival) and cost-effectiveness of selective coronary revascularization before major vascular surgery. Design: A decision-tree model was constructed to compare the cost-effectiveness of four preoperative screening strategies from the perspective of the health care system. Setting: Based on patient mortality, morbidity, and cost data from a literature review. Participants: Hypothetical cohort of patients scheduled for elective abdominal aortic aneurysm repair followed up over a 5-year period. Interventions: Patients either proceeded directly to surgery or were screened using one of three possible preoperative screening strategies. In the first strategy, all patients were screened with a dipyridamole-thallium test. In the second strategy, all patients underwent coronary angiography. The third strategy, selective screening, first divided patients into high-, intermediate-, and low-risk groups using clinical criteria. High-risk patients underwent preoperative angiography. Intermediate-risk patients were screened noninvasively, and low-risk patients proceeded directly to surgery without further testing. Measurement and Main Results: Proceeding directly to vascular surgery resulted in the poorest 5-year survival rate (77.4%) compared with preoperative risk stratification followed by selective coronary revascularization, routine noninvasive testing (86.1%), selective testing (86.0%), and routine angiography (87.9%; p = 0.00). The incremental cost-effectiveness ratio for selective testing was significantly lower than for routine angiography ($44,800/years of life saved (YLS) v $93,300/YLS; p < 0.02). Routine noninvasive testing was not cost-effective. Thirty-day mortality was the same for all four strategies ( p = 0.84). Conclusion: Selective screening before vascular surgery may improve 5-year survival and be cost-effective. Neither routine noninvasive testing nor routine angiography appears to be cost-effective compared with currently accepted medical therapies.

Prognostic value of noninvasive testing one year after orthotopic cardiac transplantation

Objectives. We sought to evaluate the prognostic value of routine noninvasive testing—stress thallium-201 imaging, rest two-dimensional echocardiography and rest equilibrium radionuclide angiography—1 year after cardiac transplantation.Background. Coronary artery vasculopathy is the most important cause of late death after orthotopic cardiac transplantation. Several clinicl variables have been identified as risk factors for development of coronary vasculopathy. Traditional noninvasive diagnostic testing has been shown to be relatively insensitive for identifying patients with angiographic vasculopathy.Methods. Results of prospectively acquired noninvasive testing in 47 consecutive transplant recipients alive 1 year after transplantation were related to subsequent survival. Other clinical variables previously shown to be associated with the development of coronary artery vasculopathy were also in3luded in the analysis.Results. The 5-year survival rate after cardiac transplantation was 81%. By univariate analysis, echocardiography (chi-square 9.21) and stress thallium-201 myocardial perfusion imaging (chi-square 16.76) were predictive for survival, whereas rest equilibrium radionuclide angiography was not. Clinical contributors to survival were donor age (chi-square 4.56), number of human leukocyte antigen mismatches (chi-square 3.06) and cold ischemic time (chi-square 3.23). By multivariate analysis, stress myocardial imaging remained the only significant predictor of survival (risk ratio 0.27; 95% confidence interval 0.06 to 0.89).Conclusions. Normal thallium-201 stress myocardial perfusion imaging 1 year after cardiac transplantation is an important predictor of 5-year survival.

Are routine non-invasive tests useful in prediction of outcome after myocardial infarction in elderly people?

Summary Many patients with acute myocardial infarction undergo tests to identify ischaemia, left-ventricular dysfunction, and arrhythmias. We examined the usefulness of these tests in clinical practice by comparing the ability of a cardiologist to predict outcome at 1 year after infarction with and without knowledge of the results of an exercise test, radionuclide angiogram, and 24 h Holter electrocardiographic (ECG) recording. The study was limited to patients older than 65 years, who have a greater risk of cardiovascular sequelae and undergo fewer interventional procedures. The patient's own cardiologist predicted outcome on a standard rating scale, based on clinical findings and routine hospital tests. He then made a second prediction after seeing the non-invasive test results. Two other cardiologists not involved in the care of the patient independently made similar predictions. Success in predicting outcome was assessed by comparison of differences between the first and second predictions in the area under receiver operating characteristic curves. During 1 year's follow-up there were 24 cardiovascular deaths and 3 recurrent myocardial infarctions among the 147 patients. There were no significant differences in mean curve areas between the first and second predictions for the patients' own cardiologist (0·62 [SE 0·06] vs 0 60 [0·06]) or the other cardiologists (0 63 [0·06] vs 0·64 [0·06] and 0·61 [0 06] vs 0·65 [0·06]). All predictions were significantly (p < 0·05) better than chance. Prediction of outcome in older patients after myocardial infarction is not improved by knowledge of the results of an exercise test, radionuclide angiogram, or 24 h Holter ECG recording.