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      Myocardial perfusion scintigraphy: the evidence : A consensus conference organised by the British Cardiac Society, the British Nuclear Cardiology Society and the British Nuclear Medicine Society, endorsed by the Royal College of Physicians of London and the Royal College of Radiologists

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          Abstract

          This review summarises the evidence for the role of myocardial perfusion scintigraphy (MPS) in patients with known or suspected coronary artery disease. It is the product of a consensus conference organised by the British Cardiac Society, the British Nuclear Cardiology Society and the British Nuclear Medicine Society and is endorsed by the Royal College of Physicians of London and the Royal College of Radiologists. It was used to inform the UK National Institute of Clinical Excellence in their appraisal of MPS in patients with chest pain and myocardial infarction. MPS is a well-established, non-invasive imaging technique with a large body of evidence to support its effectiveness in the diagnosis and management of angina and myocardial infarction. It is more accurate than the exercise ECG in detecting myocardial ischaemia and it is the single most powerful technique for predicting future coronary events. The high diagnostic accuracy of MPS allows reliable risk stratification and guides the selection of patients for further interventions, such as revascularisation. This in turn allows more appropriate utilisation of resources, with the potential for both improved clinical outcomes and greater cost-effectiveness. Evidence from modelling and observational studies supports the enhanced cost-effectiveness associated with MPS use. In patients presenting with stable or acute chest pain, strategies of investigation involving MPS are more cost-effective than those not using the technique. MPS also has particular advantages over alternative techniques in the management of a number of patient subgroups, including women, the elderly and those with diabetes, and its use will have a favourable impact on cost-effectiveness in these groups. MPS is already an integral part of many clinical guidelines for the investigation and management of angina and myocardial infarction. However, the technique is underutilised in the UK, as judged by the inappropriately long waiting times and by comparison with the numbers of revascularisations and coronary angiograms performed. Furthermore, MPS activity levels in this country fall far short of those in comparable European countries, with about half as many scans being undertaken per year. Currently, the number of MPS studies performed annually in the UK is 1,200/million population/year. We estimate the real need to be 4,000/million/year. The current average waiting time is 20 weeks and we recommend that clinically appropriate upper limits of waiting time are 6 weeks for routine studies and 1 week for urgent studies.

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          Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.

          There is continued debate as to whether a routine, early invasive strategy is superior to a conservative strategy for the management of unstable angina and myocardial infarction without ST-segment elevation. We enrolled 2220 patients with unstable angina and myocardial infarction without ST-segment elevation who had electrocardiographic evidence of changes in the ST segment or T wave, elevated levels of cardiac markers, a history of coronary artery disease, or all three findings. All patients were treated with aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban. They were randomly assigned to an early invasive strategy, which included routine catheterization within 4 to 48 hours and revascularization as appropriate, or to a more conservative (selectively invasive) strategy, in which catheterization was performed only if the patient had objective evidence of recurrent ischemia or an abnormal stress test. The primary end point was a composite of death, nonfatal myocardial infarction, and rehospitalization for an acute coronary syndrome at six months. At six months, the rate of the primary end point was 15.9 percent with use of the early invasive strategy and 19.4 percent with use of the conservative strategy (odds ratio, 0.78; 95 percent confidence interval, 0.62 to 0.97; P=0.025). The rate of death or nonfatal myocardial infarction at six months was similarly reduced (7.3 percent vs. 9.5 percent; odds ratio, 0.74; 95 percent confidence interval, 0.54 to 1.00; P<0.05). In patients with unstable angina and myocardial infarction without ST-segment elevation who were treated with the glycoprotein IIb/IIIa inhibitor tirofiban, the use of an early invasive strategy significantly reduced the incidence of major cardiac events. These data support a policy involving broader use of the early inhibition of glycoprotein IIb/IIIa in combination with an early invasive strategy in such patients.
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            Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative

             P Bossuyt (2003)
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              Guidelines for meta-analyses evaluating diagnostic tests.

              To introduce guidelines for the conduct, reporting, and critical appraisal of meta-analyses evaluating diagnostic tests and to apply these guidelines to recently published meta-analyses of diagnostic tests. Based on current concepts of how to assess diagnostic tests and conduct meta-analyses. They are applied to all meta-analyses evaluating diagnostic tests published in English-language journals from January 1990 through December 1991, identified through MEDLINE searching and by experts in the field. Meta-analyses were included if at least two of three independent readers regarded their main purpose as the evaluation of diagnostic tests against a concurrent reference standard. By three independent readers on the extent to which meta-analyses fulfilled each guideline, with consensus defined as agreement by at least two readers. The guidelines are concerned with determining the objective of the meta-analysis, identifying the relevant literature and extracting the data, estimating diagnostic accuracy, and identifying the extent to which variability is explained by study design characteristics and characteristics of the patients and diagnostic test. In general, the guidelines were only partially fulfilled. Meta-analysis is potentially important in the assessment of diagnostic tests. Those reading meta-analyses evaluating diagnostic tests should critically appraise them; those doing meta-analyses should apply recently developed methods. The conduct and reporting of primary studies on which meta-analyses are based require improvement.
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                Author and article information

                Contributors
                r.underwood@imperial.ac.uk
                Journal
                Eur J Nucl Med Mol Imaging
                European Journal of Nuclear Medicine and Molecular Imaging
                Springer-Verlag (Berlin/Heidelberg )
                1619-7070
                1619-7089
                25 November 2003
                February 2004
                : 31
                : 2
                : 261-291
                Affiliations
                [1 ]Imperial College London, Royal Brompton Hospital, Sydney St, London, SW3 6NP UK
                [2 ]Royal Brompton Hospital, Sydney St, London, SW3 6NP UK
                [3 ]Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, WA 20007-2197 USA
                [4 ]Institute of Nuclear Medicine, UCL, The Middlesex Hospital, Mortimer Street, London, W1T 3AA UK
                [5 ]Dudley Group of Hospitals, Wordsley Hospital, Stourbridge, West Midlands DY8 5QX UK
                [6 ]Antrim Area Hospital, Bush Road, Co Antrim, N. Ireland, UK
                [7 ]Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH UK
                [8 ]Northern General Hospital, Herries Road, Sheffield, S5 7AU UK
                [9 ]Institute of Nuclear Medicine, UCL, The Middlesex Hospital, Mortimer Street, London, W1T 3AA UK
                [10 ]Suite 225, Atlanta Cardiovascular Research Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342 USA
                [11 ]Castle Hill Hospital, Castle Road, Cottingham, E Yorkshire HU16 5JQ UK
                Article
                1344
                10.1007/s00259-003-1344-5
                2562441
                15129710
                © Springer-Verlag 2004
                Categories
                Review Article
                Custom metadata
                © Springer-Verlag 2004

                Radiology & Imaging

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