• Complete Hardware and Software Upgrade to Hologic Bone Density Machine
• Looping Event Recorders Purchased
• CCK Hida
• Dobutamine Myocardial Perfusion Imaging Now Available

Norfolk Nuclear Medicine Purchases Two Looping Event Recorders
In order to provide you and your patients with the best available arrhythmia monitoring system, we have purchased the King of Hearts Express, Cardiac Event Recorders and receiving station. These monitors are sophisticated yet easy-to-use cardiac event recorders. They are designed to increase yield for tough to diagnose transient symptoms such as syncope, palpitations, shortness of breath, chest discomfort and dizziness.

Along with being able to record patient-activated events, like traditional event recorders, the King of Hearts Express also has the capability to catch asymptomatic events and sudden rate changes with its unique Tachycardia and Bradycardia auto-triggers. Each trigger is programmable to meet your patient's specific needs.

The monitor features simple one-button recording for symptomatic events, 10-minutes of programmable pre and post event memory and easy two-electrode patient hook-up. The patient keeps the monitor as long as it takes to capture an event. They can either transmit the recorded ECG over the phone or present to the clinic where the ECG will be downloaded and analyzed by our technical staff and reviewed by a qualified physician.

1. 
   
2. Does a patient presenting with atypical chest pain have CAD? Answer
   
3. Is a patient with acute chest pain but non diagnostic ECG having an infarct? Answer
   
4. How do I evaluate and cost-effectively manage my patient with stable angina? Answer
   
5. Is a borderline coronary artery stenosis hemodynamically significant (i.e., likely to be responsible for or contributing to the patients symptoms)? Answer
   
6. Surgical risk: Is the patient's cardiac status adequate to tolerate major surgery? Answer
   

Q. Does an asymptomatic patient with multiple risk factors have CAD?
A. The first test is ECG. Additional screening tests for patients with risk factors for CAD include a stress ECG, a myocardial perfusion imaging study, or a stress/dobutamine echocardiogram. A positive finding on a ECG or stress ECG often leads to stress myocardial perfusion examination to identify CAD and, if present to determine the extent, severity and anatomic location of CAD and the patients prognostic assessment. Patients who are unable to stress adequately on a treadmill, including women who may have less reliable stress ECG performance, can be referred for a myocardial perfusion pharmacologic stress examination instead of the routine stress ECG. Clinical cost-effectiveness studies show that particularly for patients with pre-test low-intermediate level probabilities for CAD, the stress myocardial perfusion study should be done and followed by coronary angiography only if warranted by an abnormal perfusion study. Stress myocardial perfusion imaging is appropriate for preoperative assessment of cardiac risk and to alleviate concerns of patients with risk factors who are experiencing atypical chest pain.

Q. Does a patient presenting with atypical chest pain have CAD?
A. Patients presenting with atypical chest pain should be evaluated with careful history and physical examination. A gastrointestinal cause for atypical chest pain may be apparent without need for cardiac work up. Presence of risk factors for CAD enhance the need for further testing. In any case, if the patient's anxiety is sufficiently high or disruptive, non-invasive testing to provide peace of mind if CAD is absent or appropriate therapy if indeed CAD is present, is more compelling. An ECG would be followed by either a stress ECG test and if either of these tests is abnormal, a stress myocardial perfusion scan or dobutamine stress echocardiogram would follow.

Q. Is a patient with acute chest pain but non diagnostic ECG having an infarct?
A. In acute chest pain patients, prognostic-outcomes data show that normal or near normal myocardial perfusion scans are associated with a subsequent event rate of about 1% per year and zero deaths over the ensuing 30 days. Patients with known CAD and prior revascularization procedures have low risk for cardiac events if their perfusion scans are normal. In contrast, abnormal perfusion scans with ischemic stress defects (which reverse at rest) have high incidences of subsequent cardiac events during the following year.

Nuclear imaging can cost-effectively assist in the triage of patients with acute chest pain presenting in the ER. If the myocardial perfusion scan sows a perfusion defect, the patient should be admitted with a diagnosis of CAD and possible evolving myocardial infarct. If the scan is normal, the patient can be discharged to outpatient care, saving the costs of an unnecessary hospital admission.

Q. How do I evaluate and cost-effectively manage my patient with stable angina?
A. There is wide variation in practice patterns for evaluating patients with stable angina. the major options include noninvasive diagnostic work up such as stress ECG, stress myocardial perfusion imaging or echocardiography followed by cardiac catheterization and revascularization. A large prospective study of >11,000 consecutive stable angina patients recently showed that an initial stress myocardial perfusion imaging strategy followed by selective cardiac catheterization, compared with the direct cardiac catheterization strategy, resulted in 30-40% lower costs of care for patients at all levels of pretest clinical risk over a 3 year period. Outcomes measures of cardiac death and MI over 3 years of follow-up were the same for both groups. This study indicates that the less invasive, lower morbidity, less expensive diagnostic evaluation strategy for the individual patient with stable angina also saves health care dollars on a larger scale.

Q. Is a borderline coronary artery stenosis hemodynamically significant (i.e., likely to be responsible for or contributing to the patients symptoms)?
A. Coronary angiograms (performed at rest) show anatomic narrowing of vessels that may or may not correlate with true flow impairments at stress. The homodynamic significance of a lesion can be demonstrated by stress-induced reversible myocardial perfusion deficit in the region corresponding to the stenosed vessel's myocardial territory. If no stress perfusion deficit is elicited, the lesion is not hemodynamically significant, i.e. does not warrant revascularization, and the prognosis is good (cardiac event rate of <1% per year, which is the same as in age-matched asymptomatic controls).

Q. Surgical risk: Is the patient's cardiac status adequate to tolerate major surgery?
A. Patients who are scheduled for major surgery and who have a family history for CAD and/or other risk factors, even if asymptomatic, may be at high risk for a cardiac event. A large stress perfusion defect that normalizes at rest carries a high risk of perisurgical event. Depending on extent , severity and location of a defect, the patient may be sent for cardiac catheterization and revascularization before the scheduled surgery.

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