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Introduction This study aims to review the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) in symptomatic dural arteriovenous fistula (DAVF). Methods EMBASE, PubMed, and Cochrane Library were searched until April 2015 for studies which compared CT, MRI, or both with angiography for the detection of DAVF. The diagnostic performances of MRI and CT were indirectly compared using modality as a covariate in the analysis. Results Thirteen studies met our inclusion criteria. MRI had a sensitivity of 0.90 (95 % confidence interval (CI) = 0.83–0.94) and specificity of 0.94 (95 % CI = 0.90–0.96). CT had a sensitivity of 0.80 (95 % CI = 0.62–0.90) and specificity of 0.87 (95 % CI = 0.74–0.94). MRI showed better diagnostic performance than CT ( p  = 0.02). Contrast medium use and time-resolved MR angiography did not improve MRI diagnostic performance ( p  = 0.31 and 0.44, respectively). Conclusion Both CT and MRI had good diagnostic performance. MRI was better than CT on the detection of symptomatic intracranial dural arteriovenous fistula in the indirect comparison.

Coronary computed tomography angiography (CCTA) appears comparable to standard care, including exercise stress testing (EST), in diagnosing acute coronary syndrome in emergency department (ED) patients with chest pain but may increase downstream testing. The objective of this study was to investigate rates of post-CCTA versus post-EST testing for (1) invasive angiography and (2) all combined cardiac testing. This was a retrospective cohort study performed at 2 urban Canadian EDs involving patients aged up to 65 years with chest pain but no objective ACS findings that were evaluated with CCTA or EST at the physician's discretion. The primary outcome was the proportion of patients who had 30-day invasive angiography in each group; secondary outcomes included all subsequent 30-day cardiac testing, including nuclear medicine scanning. From July 1, 2012, to June 30, 2014, we collected 1,700 patients: 521 CCTA and 1,179 EST. Demographics and risk factors were similar in both cohorts. In the following 30 days, 30 CCTA (5.8%) and 297 EST (25.2%) patients underwent any type of additional cardiac testing (difference 19.4%, 95% CI 16.0 to 22.6), whereas 12 CCTA (2.3%) and 20 EST patients (1.7%) underwent angiography (difference 0.6%, 95% CI −0.8% to 2.6%). No patients in either group died or had a myocardial infarction within 30 days. For ED patients with chest pain who underwent brief observation, CCTA and EST had similar 30-day angiography rates, but CCTA patients underwent significantly less overall cardiac investigations.

In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model). We performed a prospective study with 30-day telephone follow-up for all chest pain patients placed in our EDOU. Halfway through the study period, our EDOU transitioned from an EP model to a CPU model. We compared provocative testing rates and outcomes between the 2 models. Over the 34-month study period, our EDOU evaluated 1190 patients for chest pain. Patients placed in the EDOU during the 17-month CPU model were more likely to be moderate risk (Thrombolysis in Myocardial Infarction score 3-5) than those during the 17-month EP model: 24.9% vs 18.8%, P = .011. Despite this difference, rates of provocative testing (stress testing or coronary computed tomography) were lower during the CPU model: 47.1% vs 56.5%, P = .001. This reduction was particularly evident among low-risk patients (Thrombolysis in Myocardial Infarction score 0-2): 49.8% vs 58.1%, P = .011. Rates of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft were similar between the 2 groups (2.8% vs 3.2%, P = .140). We noted no significant events or missed diagnoses in either group during the 30-day follow-up. An EDOU model that used mandatory cardiology consultation resulted in decreased provocative testing, particularly among low-risk chest pain patients. Future research should explore the cost-effectiveness of this model.

To evaluate risk of hospitalization due to cardiovascular disease (CVD) and repeat coronary angiography (CAG) in stable angina pectoris (SAP) with no obstructive coronary artery disease (CAD) versus obstructive CAD, and asymptomatic reference individuals. We followed 11,223 patients with no prior CVD having a first-time CAG in 1998-2009 due to SAP symptoms and 5,695 asymptomatic reference individuals from the Copenhagen City Heart Study through registry linkage for 7.8 years (median). In recurrent event survival analysis, patients with SAP had 3-4-fold higher risk of hospitalization for CVD irrespective of CAG findings and cardiovascular comorbidity. Multivariable adjusted hazard ratios(95%CI) for patients with angiographically normal coronary arteries was 3.0(2.5-3.5), for angiographically diffuse non-obstructive CAD 3.9(3.3-4.6) and for 1-3-vessel disease 3.6-4.1(range)(all P<0.001). Mean accumulated hospitalization time was 3.5(3.0-4.0)(days/10 years follow-up) in reference individuals and 4.5(3.8-5.2)/7.0(5.4-8.6)/6.7(5.2-8.1)/6.1(5.2-7.4)/8.6(6.6-10.7) in patients with angiographically normal coronary arteries/angiographically diffuse non-obstructive CAD/1-, 2-, and 3-vessel disease, respectively (all P<0.05, age-adjusted). SAP symptoms predicted repeat CAG with multivariable adjusted hazard ratios for patients with angiographically normal coronary arteries being 2.3(1.9-2.9), for angiographically diffuse non-obstructive CAD 5.5(4.4-6.8) and for obstructive CAD 6.6-9.4(range)(all P<0.001). Patients with SAP symptoms and angiographically normal coronary arteries or angiographically diffuse non-obstructive CAD suffer from considerably greater CVD burdens in terms of hospitalization for CVD and repeat CAG compared with asymptomatic reference individuals even after adjustment for cardiac risk factors and exclusion of cardiovascular comorbidity as cause. Contrary to common perception, excluding obstructive CAD by CAG in such patients does not ensure a benign cardiovascular prognosis.

Purpose The study objective was to compare dye angiography and optical coherence tomography angiography (OCTA) in detecting choroidal neovascuarization (CNV) in patients presenting with pachychoroid features and flat irregular pigment epithelial detachment (PED). Methods Nineteen eyes of 17 patients, presenting with flat PED and pachychoroid features, and without age-related macular degeneration or any other degenerative change, were analyzed. Fuorescein angiography (FA)/Indocyanine green angiography (ICGA) and OCTA were performed during the same visit. Subfoveal choroidal thickness was measured by enhanced depth imaging using spectral domain optical coherence tomography. Results The mean age of the patients was 59.1 years. Mean subfoveal choroidal thickness was 388 μm. FA revealed non-patognomic features including RPE alterations, window defects, leaking points and leakage from an undetermined source. ICGA revealed choroidal vascular plaque in eight eyes (42%) and suspicious plaque in five eyes (26%). Nonneovascular features, such as hyperpermeability or dilated choroidal vessels, were observed in six eyes (32%). OCTA showed choroidal neovascularization in 14 (74%). For all of the eyes, which ICGA was positive for presence of CNV, OCTA also showed CNV, and in one case it also revealed polypoidal characteristics of the neovascular network. OCTA was also able to detect CNV in all of the eyes with suspicious plaque, and in one eye without CNV appearance using ICGA. Conclusions OCTA demonstrated greater sensitivity in detecting type 1 CNV than conventional dye angiography in cases with pachychoroid spectrum disease.

Splenic artery embolization (SAE) in the presence of contrast blush (CB) has been recommended to reduce the failure rate of nonoperative management. We hypothesized that the presence of CB on computed tomography has minimal impact on patient outcomes. A retrospective review was conducted of all children (<18 years) with blunt splenic trauma over a 10-year period at a level 1 pediatric trauma center. Data are presented as mean ± standard error of mean. Seven hundred forty children sustained blunt abdominal trauma, of which 549 had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 of the 740 patients. All patients were managed nonoperatively without SAE. CB was seen on computed tomography in 47 patients (17.4%). There were no significant differences in the need for blood transfusion (12.5% vs 11.1%) or length of stay (3.1 vs 3.3 days) or need for splenectomy when compared in children with or without CB. Pediatric trauma patients with blunt splenic injuries can be safely managed without SAE and physiologic response and hemodynamic stability should be the primary determinants of appropriate management.

A registry mandated by the European Society of Cardiology collects data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in new techniques and their distributions across Europe. We report the data through 2004 and give an overview of the development of coronary interventions since the first data collection in 1992. Questionnaires were distributed yearly to delegates of all national societies of cardiology represented in the European Society of Cardiology. The goal was to collect the case numbers of all local institutions and operators. The overall numbers of coronary angiographies increased from 1992 to 2004 from 684 000 to 2 238 000 (from 1250 to 3930 per million inhabitants). The respective numbers for percutaneous coronary interventions (PCIs) and coronary stenting procedures increased from 184 000 to 885 000 (from 335 to 1550) and from 3000 to 770 000 (from 5 to 1350), respectively. Germany was the most active country with 712 000 angiographies (8600), 249 000 angioplasties (3000), and 200 000 stenting procedures (2400) in 2004. The indication has shifted towards acute coronary syndromes, as demonstrated by rising rates of interventions for acute myocardial infarction over the last decade. The procedures are more readily performed and perceived safer, as shown by increasing rate of \"ad hoc\" PCIs and decreasing need for emergency coronary artery bypass grafting (CABG). In 2004, the use of drug-eluting stents continued to rise. However, an enormous variability is reported with the highest rate in Switzerland (70%). If the rate of progression remains constant until 2010 the projected number of coronary angiographies will be over three million, and the number of PCIs about 1.5 million with a stenting rate of almost 100%. Interventional cardiology in Europe is ever expanding. New coronary revascularization procedures, alternative or complementary to balloon angioplasty, have come and gone. Only stenting has stood the test of time and matured to the default technique. Facilitated access to PCI, more complete and earlier detection of coronary artery disease promise continued growth of the procedure despite the uncontested success of prevention.

We hypothesized that PET myocardial perfusion imaging with (82)Rb (PET MPI), would reduce downstream utilization of diagnostic arteriography, compared with SPECT, in patients matched for pretest likelihood of coronary disease (pCAD). PET MPI is more accurate for assessment of impaired coronary flow reserve compared with SPECT MPI, potentially reducing the demand for subsequent arteriography, percutaneous trans-coronary intervention, and coronary artery bypass grafting (CABG), with attendant cost savings, while avoiding a negative impact on coronary events. The frequency of diagnostic arteriography, revascularization, costs, and 1-y clinical outcomes in 2,159 patients studied with PET MPI was compared with 2 control groups studied with SPECT MPI matched to the PET group by pCAD: an internal control group of 102 patients and an external SPECT control group of 5,826 patients. CAD management costs were approximated with realistic global fee estimates. Arteriography rates were 0.34 and 0.31 for the external and internal control SPECT groups and 0.13 for the patients studied with PET (P < 0.0001). pCAD averaged 0.39 in patients studied with PET MPI, and in the external SPECT control group, and 0.37 in the internal SPECT controls. Revascularization rates were 0.13 and 0.11 for external and internal SPECT patients and 0.06 for the PET group (P < 0.0001; P < 0.01), with a cost savings of 30% noted for PET patients, with no significant difference in cardiac death or myocardial infarction at 1-y follow-up. PET MPI in patients with intermediate pCAD results in a >50% reduction in invasive coronary arteriography and CABG, a 30% cost savings, and excellent clinical outcomes at 1 y compared with SPECT.

Universal health care systems have been organized in most industrialized nations with a view to ensuring equitable access to medical services and improving health status for all citizens. Canada's federal–provincial Medicare plan covers all medically necessary services provided by hospitals and physicians without any user fees and is based on the principle of access according to need rather than income. 1 , 2 Considerable evidence suggests that Medicare has improved access to health services for poorer Canadians, 3 , 4 but some studies have found that those of low socioeconomic status remain less likely to receive specific services than wealthier patients. 3 , 5 – 7 Several . . .

The appropriate use criteria (AUC) were developed to aid clinicians in making clinical decisions regarding coronary angiography. The aim of the present study was to evaluate the association between the publication of the AUC criteria in diagnostic angiography and rates of angiography in Ontario. Our cohort consisted of all patients who underwent coronary angiography in Ontario from 1st October 2008 to 31st October 2013 for the indication of suspected stable coronary artery disease. We determined monthly age- and sex-standardized rates of angiography per 100,000 adults. To determine the association between the publication of the AUC for diagnostic angiograms and the rates of angiography, we conducted a time series analysis using an autoregressive integrated moving average model. As a sensitivity analyses, we evaluated the impact of the AUC on the rates of percutaneous coronary intervention (PCI) per 100 angiograms. We included 114,551 angiograms for stable coronary artery disease. In the period prior to the publication of the AUC, the average monthly age- and sex-standardized rate of angiography was 18.7 per 100,000; post-AUC, the average monthly rate decreased to 17.6 per 100,000 adults (P = .037). In contrast, in the 29,358 PCIs included in the analysis, the monthly PCI rates per 100 angiograms were unchanged (25.2 pre-AUC; 26.8 post-AUC; P = .29). In the sensitivity analysis, the rate of appropriate/inappropriate and uncertain indication did not significantly change over the study period. The publication of the diagnostic angiography AUC criteria was associated with a decrease in the population rates of diagnostic angiography. This suggests that the AUC potentially was associated with an increased threshold to pursue invasive diagnostic testing.