Cardiac Positron Emission Tomography (PET) can be used for the assessment of myocardial perfusion. Compared to other cardiac imaging techniques, notably Single Photon Emission Computer Tomography (SPECT), cardiac PET offers superior image resolution, higher accuracy, quantitative measures of myocardial perfusion, lower radiation exposure, and shorter image acquisition time. However, PET tends to be costlier and less widely available than SPECT due to the specialized equipment needed for generating the necessary radiotracers. Despite these challenges, PET has emerged as the preferred imaging modality for evaluating coronary artery disease due to its exceptional accuracy and broad applicability. Enhancing access to PET is anticipated to significantly improve the diagnosis and treatment of patients with cardiac conditions that might otherwise remain inadequately assessed.

Chest pain is one of the most common chief complaints seen in both the emergency department (ED) and primary care settings.1,2 It is estimated that 20-40% of the general population will suffer from chest pain at some point throughout their lives.3 Interestingly although obstructive coronary artery disease (CAD) prevalence has declined, chest pain as a presenting symptom has become increasingly common over the last decade.4 Chest pain can stem from different organ systems including cardiac, pulmonary, gastrointestinal, musculoskeletal, or psychiatric.5,6 However, only about 18% of chest pain is diagnosed as cardiac in nature.7 Cardiac chest pain, in itself, has a broad differential including ischemic CAD, but can also be a result of non-ischemic causes such as valvopathies, myocarditis, pericarditis, aortic dissection, or heart failure.8 Ischemic chest pain can be broken into life-threatening acute coronary syndrome (ACS), unstable angina, or stable angina. Discerning the etiology of chest pain based on history and physical exam alone is challenging as symptomatology can overlap with multiple organ systems.9 Therefore, physicians often rely on testing to reach a diagnosis, a practice which costs the United States healthcare system billions of dollars per year.4 In this review, we aim to identify the cardiac-testing modalities available to clinicians to accurately diagnose a cause of chest pain and consider which test might be most appropriate for patients evaluated in the ambulatory or ED setting.

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide, necessitating advancements in diagnostic techniques. Coronary CT angiography (CCTA) has emerged as a pivotal non-invasive tool for evaluating coronary artery anatomy and detecting atherosclerotic plaque burden with high spatial resolution. This review explores the evolution of CCTA, highlighting its technological advancements, clinical applications, and challenges. Key innovations such as multidetector CT, photon-counting CT, and functional assessment tools like FFR-CT have enhanced CCTA's diagnostic and prognostic capabilities. Despite these advancements, issues related to radiation exposure, iodinated contrast, and patient-specific limitations persist. Future directions include the development of novel imaging biomarkers and strategies to minimize radiation exposure. By synthesizing existing literature and recent developments, this paper provides a comprehensive understanding of CCTA's role in contemporary CAD management.

This document from the American Society of Nuclear Cardiology develops metrics for the assessment of quality for laboratories that perform cardiac amyloid radionuclide imaging. These metrics are based on clinical guidelines, appropriate use criteria, information and position statements, and expert opinion. The document introduces 15 quality metrics that address current gaps in care organized around 4 axes: A) Appropriate indications; B) Patient experience and workflow; C) Instrumentation and protocols; and D) Interpretation and reporting. With the increasing use of imaging for cardiac amyloid, it is imperative that our laboratories maintain a high level of quality to preserve the value that imaging provides to patients. Laboratories should perform imaging in appropriately selected patients avoiding low-value imaging. Proper education should be provided to patients prior to performing testing, timely access to testing must be available, and periodic assessment of patient experience and satisfaction should be the norm. Strict adherence to established protocols with periodic assessment of laboratory quality control is essential. Laboratory studies to rule out plasma cell dyscrasia should be performed in all patients suspected of having cardiac amyloidosis. Crucially, interpretation should be based on SPECT rather than planar imaging in all patients. The study report should include sufficient technical details to allow for proper interpretation of study findings and its conclusion should be clear and unambiguous to guide clinical management. Laboratories can use data derived from these metrics to identify areas of deficiency and introduce quality improvement initiatives, which will ultimately improve patient outcomes.

As cardiovascular care continues to advance and with an aging population with higher comorbidities, the epidemiology of the cardiac intensive care unit has undergone a paradigm shift. There has been increasing emphasis on the development of multidisciplinary teams (MDTs) for providing holistic care to complex critically ill patients, analogous to heart teams for chronic cardiovascular care. Outside of cardiovascular medicine, MDTs in critical care medicine focus on implementation of guideline-directed care, prevention of iatrogenic harm, communication with patients and families, point-of-care decision-making, and the development of care plans. MDTs in acute cardiovascular care include physicians from cardiovascular medicine, critical care medicine, interventional cardiology, cardiac surgery, and advanced heart failure, in addition to nonphysician team members. In this document, we seek to describe the changes in patients in the cardiac intensive care unit, health care delivery, composition, logistics, outcomes, training, and future directions for MDTs involved in acute cardiovascular care. As a part of the comprehensive review, we performed a scoping of concepts of MDTs, acute hospital care, and cardiovascular conditions and procedures.

A 23-year-old man sustained blunt cardiac injury after a motor vehicle collision resulting in left ventricular septal avulsion, ruptured chordae tendineae, and moderate to severe tricuspid regurgitation that necessitated opera-tive intervention. The patient underwent successful resection of a prolapsed avulsed septal wall segment and concomitant tricuspid valve repair.(Ann Thorac Surg 2023;116:e9-e12)& COPY; 2023 by The Society of Thoracic Surgeons

Background: Prosthetic valve endocarditis continues to be a lifethreatening complication of valve replacement.Accurate and early detection is necessary to facilitate appropriate treatment.Methods: This is a retrospective study of patients with a high clinical suspicion of prosthetic valve endocarditis and with an equivocal, negative, or non-diagnostic transesophageal echocardiogram who were sent for PET FDG imaging for further evaluation of PVE.The patients were sent at the discretion of the primary care team and, in most cases, infectious diseases (no protocol was in place).Standard PET protocol for FDG inflammation was followed.Results: 36 patients had PET FDG imaging.89% (32 of 36) had a negative, equivocal or non-diagnostic transesophageal echocardiogram prior to PET FDG.75% (27 of 36) of the FDG PET studies were positive for inflammation consistent with prosthetic valve endocarditis.12% (4 of 32) who had an initially negative TEE and positive PET FDG scan, had a subsequent transesophageal echocardiogram that was consistent with PVE.Chart review was done all patients for treatment and outcome, infectious diseases team was involved in all cases Conclusions: PVE is difficult to diagnose and treat.FDG PET may be helpful in the diagnosis of PVE when there is a high index of clinical suspicion in the setting of a non-diagnostic echocardiogram.Further study with longitudinal follow-up is needed to determine clinical outcomes after FDG-PET.

Introduction: The pathogenesis of myocardial dysfunction in light-chain (AL) cardiac amyloidosis is poorly understood.The aim of the present study is to evaluate the relationship between left ventricular (LV) myocardial mechanical external efficiency (MEE), myocardial blood flow (MBF), and myocardial function in patients with AL amyloidosis.Methods: This prospective study enrolled 57 biopsy-proven AL amyloidosis patients.Cardiac involvement was defined by recent multisocietal consensus criteria (NT-proBNP, wall thickness, extracellular volume (ECV) and global longitudinal strain (GLS)).All subjects underwent 11C-acetate positron emission tomography (PET); myocardial oxygen consumption (MVO2) and MBF were assessed from the clearance (k2) and inflow rate constant (k1), respectively.MEE was calculated as (stroke volume*heart rate*mean arterial blood pressure*1.33*10 - )/(myocardial mass*MVO2*20)*100 using stroke volume and mass from MRI. MBF was adjusted by rate-pressure-product (RPP).Results: Cardiac involvement was present in 43 patients (75%).In these patients, MEE and MBF were significantly impaired as compared to patients without cardiac involvement (MEE: 11% [8-15] vs. 15% [11-22], P = .023;MBF: 0.57 mLÁminÁg [0.46-0.75] vs. 0.96 mLÁminÁg [0.81-1.07],P \ .001).Neither MEE nor MBF correlated with revised Mayo stage, 6-minutes walking distance , and quality of life from Minnesota Living with Heart Failure Questionnaire.In patients with cardiac involvement, both MEE and MBF were moderately correlated with systolic function (GLS), while only MEE was moderately correlated with diastolic function (E/e 0 ); in patients without cardiac involvement, no significant correlations were observed (Figure).Conclusions: Systolic dysfunction in cardiac AL amyloidosis is related to impaired myocardial blood flow and to energetic inefficiency, while diastolic dysfunction is primarily related to energetic inefficiency..

We report a case of isolated cardiac sarcoidosis (CS) diagnosed using a multimodality imaging approach. A patient presented after an out-of-hospital, ventricular fibrillation–mediated cardiac arrest. The use of echocardiography, cardiac magnetic resonance, and fluorodeoxyglucose-positron emission tomography enabled the diagnosis of isolated CS. (Level of Difficulty: Beginner.)

It is estimated that 25% of patients with sarcoidosis have isolated cardiac sarcoidosis (ICS). The use of cardiac imaging to diagnosis ICS has become a valuable option when tissue sampling is not feasible. A 72-year old female with a history of high-grade AV block (Figure A) presented after a

This information statement from the American Society of Nuclear Cardiology highlights advances in cardiac SPECT imaging and supports the incorporation of new technology and techniques in laboratories performing nuclear cardiology procedures. The document focuses on the application of the latest imaging protocols and the utilization of newer hardware and software options to perform high quality, state-of-the-art SPECT nuclear cardiology procedures. Recommendations for best practices of cardiac SPECT imaging are discussed, highlighting what imaging laboratories should be doing as the standard of care in 2018 to achieve optimal results (based on the ASNC 2018 SPECT guideline [Dorbala et al., J Nucl Cardiol. 2018. https://doi.org/10.1007/s12350-018-1283-y ]).

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

There is a need for consensus recommendations for ionizing radiation dose optimization during multimodality medical imaging in children with congenital and acquired heart disease (CAHD). These children often have complex diseases and may be exposed to a relatively high cumulative burden of ionizing radiation from medical imaging procedures, including cardiac computed tomography, nuclear cardiology studies, and fluoroscopically guided diagnostic and interventional catheterization and electrophysiology procedures. Although these imaging procedures are all essential to the care of children with CAHD and have contributed to meaningfully improved outcomes in these patients, exposure to ionizing radiation is associated with potential risks, including an increased lifetime attributable risk of cancer. The goal of these recommendations is to encourage informed imaging to achieve appropriate study quality at the lowest achievable dose. Other strategies to improve care include a patient-centered approach to imaging, emphasizing education and informed decision making and programmatic approaches to ensure appropriate dose monitoring. Looking ahead, there is a need for standardization of dose metrics across imaging modalities, so as to encourage comparative effectiveness studies across the spectrum of CAHD in children.

James C. Blankenship Brian G. Abbott Joann Lindenfeld Susan E. Wiegers Ken Rosenfield Decades ago, it would have been enough. But as medical sub-specialization has become common, the importance of sub-specialty organizations has increased. Now, more often than not, expertise in one's field of practice is demonstrated by fellowship in a medical sub-specialty organization. However, medical society membership is expensive. You have to ask yourself: Is it worth it? For our societies, the answer is an emphatic “Yes!”. Physicians cite recognition, education, and advocacy as the most important benefits of membership in professional societies. Sub-specialty societies offer the most bang for the buck in all three of these areas. In this era, membership in the American College of Cardiology (ACC) is routine for cardiologists. It implies competence in general cardiology. However, cardiology has become a discipline of sub-specialists, and most physicians expect a higher level of competence when they refer patients for specialized cardiology services. Membership in the relevant sub-specialty organization implies that special expertise. If a cardiologist claims special expertise in a particular sub-specialty of cardiology but is not a member of that sub-specialty's society, colleagues or patients may question whether the physician is truly dedicated to that field. On the other hand, membership should result in recognition of special expertise in that field. Sub-specialty societies also offer opportunities for recognition based on work within the sub-specialty. Members can work on committees and rise to leadership positions, serve on writing committees for consensus papers and guidelines, and lecture at society educational conferences. Members can represent their society at Food and Drug Administration Panels, Centers for Medicare & Medicaid Services (CMS) panels, state technology assessment panels, third party payer advisory groups, inter-society guidelines writing groups, appropriate use panels, and American Medical Association (AMA) committees. All of these provide valuable learning opportunities and the chance to gain recognition among peers. Finally, sub-specialty societies often recognize members' scientific or societal contributions through awards, fellowships, training grants, and research funding. In many cases these significant achievements would go unnoticed by larger medical societies. The second big benefit of sub-specialty membership is educational opportunities. Sub-specialty societies are in the best position to assess members'; sub-specialty educational needs and design programs to meet them. Within cardiology, the fields of electrophysiology, intervention, and heart failure have recently gained status as independent specialties based on their unique bodies of knowledge. The advanced imaging modalities have become so technical that few can master all of them 1. In addition, metrics of quality of care, appropriateness, and clinical effectiveness are often specific to a sub-specialty and can be most effectively communicated within the sub-specialty context. Hands-on simulation of procedures or work-station reconstruction of images will increasingly be used for education. In all of these cases, sub-specialty societies are in a unique position to develop and provide access to conferences and on-line educational opportunities needed to stay current in these areas. Sub-specialty societies also offer more intimate educational opportunities. Attendees at sub-specialty national meetings often cite the opportunity to interact with world-class physicians in small groups in an intimate setting as one of the biggest benefits. Many sub-specialty societies offer special programs for trainees and early career members to obtain special education, research mentorship, or leadership training. Because of their smaller size, these can be more intimate, nimble, and focused than programs offered by large medical societies. Sub-specialty journals offer additional opportunities for publishing, and are focused on the area of sub-specialty interest. While some general cardiology journals have recently developed “daughter” sub-specialty journals, journals of the sub-specialty societies provide the most traditional and focused source of information to their members. The third major benefit of sub-specialty membership is advocacy focused on the concerns of that sub-specialty. In some areas of advocacy, large medical societies may be paralyzed by competing interests within the society. In contrast, sub-specialty societies can focus on advocacy interests specific to their members with much greater effect. By virtue of their smaller size, sub-specialty societies are more nimble. Advocacy challenges can be addressed more quickly and efficiently. Examples include the designation of electrophysiology and interventional cardiology by CMS as independent specialties, allowing members to bill referrals from other cardiologists as consults. This recognition by CMS resulted from the tireless advocacy efforts of the three societies. Similarly, recognition by the AMA as independent specialties allows them to have representatives at the AMA CPT Editorial Panel, the AMA Relative Value Update Committee, and the AMA House of Delegates. Sub-specialty societies routinely have representatives on ACC/American Heart Association guideline writing groups and appropriate use criteria writing and rating panels. Sub-specialty societies can recognize and deal with needs for advocacy-oriented position papers and consensus documents in niche areas that larger medical societies cannot address. Sub-specialty societies can also offer opportunities for recognition, education, and advocacy to cardiovascular non-physician professionals. Most of these professionals would not be eligible for membership in larger physician-dominated medical societies, but due to close working relationships with physicians who understand their value to sub-specialty teams, these professionals can be brought into sub-specialty societies and offered their own opportunities for leadership, education, and advocacy oriented toward the needs of these professionals. Perhaps the most compelling reason of all to join a sub-specialty society is to have a medical home. Batlivala notes “Having a professional home where you are a member of a group can provide a sense of community, of belonging, and of unified purpose” 2. He advises early career physicians to find such a medical home. We would argue that it is important for all physicians to have a medical home where they can find that sense of intimate community. Sub-specialty societies offer opportunities to engage with smaller groups of like-minded people, find a common passion, work together for good purposes, renew each other, and improve the care we provide to our patients. Sub-specialty societies are intimate, nimble, and responsive to members'; needs. They allow opportunities for engagement, leadership, and recognition; opportunities for specific and useful education; and effective and focused advocacy efforts. Your sub-specialty society is the place to find your medical home.