cumulative radiation dose to the breast was 10.8cGy (range, 0–170). Seventy-seven breast cancer deaths were observed compared with 45.6 expected deaths on the basis of United States mortality rates. Women with scoliosis had a 1.7-fold risk of dying of breast cancer (95% CI, 1.3–2.1) when compared with the general population. The data suggested that radiation was the causative factor, with risk increasing significantly with the number of radiographic exposures and the cumulative radiation dose (moderate evidence). Potential confounding was noted because the severity of disease was related to radiation exposure and reproductive history; patients with more severe disease were less likely to become pregnant and had a greater risk of breast cancer. In a large retrospective cohort study of 2039 patients, Levy and col- leagues (75) found an excess lifetime cancer risk of 1% to 2% (12 to 25 cases per 1000 population) among women (moderate evidence). The same group suggested that supplanting the anteroposterior (AP) view with the pos- teroanterior (PA) view would result in a three- to sevenfold reduction in cumulative doses to the thyroid gland and the female breast, three- to four- fold reductions in the lifetime risk of breast cancer, and a halving of the lifetime risk of thyroid cancer (76). The same cohort of women was evalu- ated for adverse reproductive outcomes (77). Of the initial group of 1793 young women evaluated for scoliosis between 1960 and 1979, 1292 women returned questionnaires in 1990. This cohort was compared with a refer- ence group of 1134 women selected randomly from the general population. The adolescent idiopathic scoliosis cohort had a higher risk of spontaneous abortions [odds ratio (OR), 1.35; 95% CI, 1.06–1.73] (moderate evidence). The odds of unsuccessful attempts at pregnancy (OR, 1.33; 95% CI, 0.84–2.13) and of congenital malformations (OR, 1.2; 95% CI, 0.78–1.84) were also higher but not statistically significant (moderate evidence). Digital radiography seems to reduce radiation exposure. The results are varied (78–80), and the technology is evolving (limited evidence). Studies report an 18-fold reduction with some systems (73) versus an almost twofold increase with others (81). VII. What Is the Use of Magnetic Resonance Imaging (MRI) for Severe Idiopathic Scoliosis? Summary of Evidence: There is increasing concern about the association of idiopathic scoliosis with structural abnormalities of the neural axis. Minimal tonsillar ectopia (<5mm) is significantly prevalent in scoliosis and correlates with abnormalities in somatosensory-evoked potentials and with the severity of scoliosis (4) (moderate evidence). Otherwise, a paucity of significant findings on MRI of patients evaluated for idiopathic scolio- sis is noted, even in severe cases (4). Supporting Evidence: Cheng and colleagues (82) studied 36 healthy control subjects, 135 patients with moderately severe adolescent idiopathic scolio- sis (Cobb angle less than 45 degrees), and 29 similar patients with Cobb angles greater than 45 degrees. All of the patients were evaluated pros- pectively with MRI looking specifically for tonsillar ectopia and with somatosensory-evoked potentials. Tonsillar herniation was found in none of the controls versus four of 135 (3%) and eight of 29 (27.6%) of the two scoliotic groups (p < .001) (moderate evidence). Similarly, the percentages 344 L.S. Medina et al. of patients with abnormal somatosensory-evoked potentials were 0%, 11.9%, and 27.6%, respectively. There was a significant association between tonsillar ectopia and abnormal somatosensory function (p < .001; correla- tion coefficient, 0.672) (moderate evidence). Tonsillar ectopia was defined as any inferior displacement of the tonsils, and none of the patients had a displacement greater than 5mm, which is considered the usual threshold for the diagnosis (83–85). Several studies have addressed the prevalence of MR abnormalities in patients with severe idiopathic scoliosis who are otherwise asymptomatic. Do and colleagues (86) studied a consecutive series of 327 patients with idiopathic scoliosis requiring surgical intervention (average preoperative curve of 57 degrees) but without neurologic findings. The patients, aged 10 to 19 years, were evaluated from the base of the skull to the sacrum. Seven patients had abnormal MRI, including two with syrinx, four with Chiari malformation type I, and one with a fatty vertebral body. None of them required specific treatment for these findings (moderate evidence). In four other cases, equivocal MRI findings necessitated additional workup. In a similar prospective double-blinded study of 140 patients eval- uated preoperatively, Winter et al. (87) found four patients with abnor- malities, three with Chiari I malformations, and one with a small syrinx, none of whom required treatment. In another study of MRI examinations performed preoperatively, Maiocco et al. (88) found two of 45 patients with syrinx, one requiring decompression (moderate evidence). To study whether the severity of the curve increased the risk of associ- ated abnormalities, O’Brien et al. (89) performed MR evaluation on 33 con- secutive patients with adolescent idiopathic scoliosis and Cobb angles greater than 70 degrees. No neural axis abnormalities were found (limited evidence). VIII. What Is the Use of MRI for High-Risk Subgroups of Scoliosis? Summary of Evidence: Unlike adolescent idiopathic scoliosis, juvenile and infantile idiopathic scoliosis and congenital scoliosis have a high incidence of neural axis abnormalities (limited evidence). Increased incidence of neural axis abnormalities have been seen with atypical idiopathic scoliosis and left (levoconvex) thoracic scoliosis (Figs. 18.3 and 18.4) (4) (limited evidence). Supporting Evidence: Several studies have shown that, with scoliosis types that are different from the typical adolescent idiopathic form, there is a high prevalence of neural abnormalities (4). Of 30 consecutive children with congenital scoliosis studied by Prahinski and colleagues (90), nine had syringomyelia. Of these children, one required release of the tethered cord and one correction of a diastematomyelia (limited evidence). Two studies of prepubertal children suggest a high incidence of neural abnormalities in juvenile and infantile scoliosis. In a study of 26 consecutive children aged less than 11 years, Lewonowski and colleagues (91) found five (19.2%) with abnormalities of the cord. Three required surgical intervention, two with hydromyelia and one with a mass (91) (limited evidence). Gupta and colleagues (92) found that six of 34 patients under 10 years of age studied prospectively had neural axis abnormalities, including two patients with Chapter 18 Imaging of Spine Disorders in Children 345 syrinx requiring syringopleural shunting (one with a Chiari I malforma- tion). Other abnormalities included dural ectasia, tethered cord, and a brainstem astrocytoma (limited evidence). In a retrospective review of 95 patients with idiopathic scoliosis who had been studied for various indications, Schwend and colleagues (93) found that 12 had a syrinx, one a cord astrocytoma, and one dural ectasia (limited evidence). Left thoracic scoliosis was the most important predictor of abnormality (10 abnormalities in 43 patients). Mejia et al. (94) then per- formed a prospective study (level II) of 29 consecutive patients with idio- pathic left thoracic scoliosis, finding only two with syrinx and no other abnormalities (limited evidence). Barnes and colleagues (37) retrospec- tively analyzed 30 patients with atypical idiopathic scoliosis and found 17 abnormalities in 11 patients, including seven cases of syringohydromyelia and five Chiari I malformations (limited evidence). Take-Home Data How Should Physicians Evaluate Newborns with Suspected Occult Spinal Dysraphism? The decision tree in Figure 18.5 reinforces the primary importance of a careful acquisition of a medical history and performance of a thorough examination in newborns with suspected spinal dysraphism (30). For those patients in the high-risk group, imaging of the spine with MRI is recom- mended. For those patients in the intermediate-risk group, imaging of the spine with MRI or ultrasound is suggested, while in the low-risk group the strategies of ultrasound or no imaging may be indicated. Selection between 346 L.S. Medina et al. Figure 18.5. Suggested decision tree for use in newborns with suspected occult spinal dysraphism. For those patients in the high-risk group MRI is recommended. For patients in the intermediate-risk group ultrasound (US) or MRI is the strategy of choice, while for the low-risk group ultrasound or no imaging is recommended. For patients with negative imaging studies close clinical follow-up with periodic reassessment is recommended. [Source: Medina et al. (30), with permission.] these two strategies per risk group may be based on individual and insti- tutional diagnostic performance and cost per test. In newborns with sus- pected occult dysraphism, appropriate selection of patients for imaging based on these risk groups may maximize health outcomes for patients and improve health care resource allocation. How Should Scoliosis Be Evaluated? Figure 18.6 summarizes the decision tree for patients with suspected scoliosis. Imaging Case Study of Spinal Dysraphism This imaging case study illustrates a child with skin stigmata (Fig. 18.1) who has an occult dysraphic lesion of the intradural lipoma type (Fig. 18.2). Imaging Case Study of Scoliosis This imaging case study illustrates a child with atypical levoconvex tho- racic scoliosis (Fig. 18.3) who has neurofibromatosis type 1 with underly- ing plexiform neurofibromas (Fig. 18.4). Chapter 18 Imaging of Spine Disorders in Children 347 Figure 18.6. Suggested decision tree for use in patients with suspected scoliosis. Decision tree emphasizes importance of clinical history, physical exam, and radiographs in determining the need for MRI. Suggested Imaging Protocols for Spinal Dysraphism Spinal Ultrasound Spinal ultrasound should be performed in patients before the age of 3 months to avoid the limited acoustic window from mineralization of the posterior elements. An experienced operator should perform the study using a high-frequency, 5- to 15-MHz linear array transducer (52). Entire Spine MRI A retrospective case-control study including 101 patients (moderate evi- dence) suspected of having occult lumbosacral dysraphism demonstrated that conventional three-plane T1-weighted lumbosacral MRI in children and young adults provided better diagnostic information than a fast screening two-plane T1-weighted MRI because of its higher specificity and interobserver agreement (20). T2-weighted images in the axial and sagittal plane are often added to the protocol to assess intrinsic cord abnormali- ties. Intravenous paramagnetic contrast is not routinely used, unless the patient has a communicating dorsal dermal sinus tract or clinical concerns of underlying infection. Suggested Imaging Protocols for Scoliosis Scoliosis Radiographs Radiographs should be performed only when clinically indicated. Using the posteroanterior projection greatly reduces exposure, and some digital systems also decrease radiation (4,73). Entire Spine MRI Patients with scoliosis may represent an imaging challenge. In patients with scoliosis being evaluated with MRI, the entire spine should be covered. Three plain T1- and T2-weighted images should be obtained with different obliquities to optimize imaging information. Another approach is to obtain three-dimensional fast spin echo (FSE) volumetric imaging. Weinberger and colleagues (95) recommend using a TR of 500 ms, TE eff of 21ms, echo train length (ETL) of 8, 20- to 38-cm field of view, 256 ¥ 256 in plane matrix, 1-mm sagittal partition thickness, one excitation, and 16kHz of receive bandwidth. Intravenous paramagnetic contrast is important in the evaluation of intramedullary and extramedullary neoplasm. Future Research • Formal cost-effectiveness analysis of imaging in children with scoliosis. • Further development of low or no radiation imaging techniques for patients with scoliosis. References 1. Pacheco-Jacome E, Ballesteros MC, Jayakar P, Morrison G, Ragheb J, Medina LS. Neuroimag Clin North Am 2003;13:327–334. 348 L.S. Medina et al. 2. Soonawala N, Overweg-Plandsoen WCG, Brouwer OF. Clin Neurol Neurosurg 1999;101:11–14. 3. Tortori-Donati P, Cama A, Rosa ML, Andreussi L, Taccone A. Neuroradiology 1990;31:512–522. 4. Jaramillo D, Poussaint TY, Grottkau BE. Neuroimag Clin North Am 2003;13: 335–341. 5. Oestreich AE, Young LW, Young Poussaint T. Skeletal Radiol 1998;27(11): 591–605. 6. Shahcheraghi GH, Hobbi MH. J Pediatr Orthop 1999;19(6):766–775. 7. DiPietro MA. Radiology 1993;188:149–153. 8. Rowland Hill CA, Gibson PJ. AJNR 1995;16:469–472. 9. Wilson DA, Prince JR. AJNR 1989;10:259–262. 10. Beek FJ, de Vries LS, Gerards LJ, Mali WP. Neuroradiology 1996; 38(suppl):S174–177. 11. Barson AJ. J Anat 1970;106:489–497. 12. Warder DE, Oakes WJ. Neurosurgery 1993;33:374–378. 13. Haworth JC, Zachary RB. Lancet 1955;2:10–14. 14. Milhorat TH, Miller JI. Neurosurgery. In: Avery GB, Fletcher MA, Mhairi GM, eds. Neonatology (4th ed). Philadelphia: JB Lippincott, 1994:1155–1163. 15. Kalter H, Warkany J. Medical progress. N Engl J Med 1983;308:424–431. 16. Bird TD, Hall JG. Neurology 1977;27:1057–1060. 17. Vintzileos AM, Ananth CV, Fisher AJ, et al. Am J Obstet Gynecol 1999; 180(5):1227–1233. 18. Knight GJ, Palomaki GF. Maternal serum alpha-fetoprotein and the detection of open neural tube defects. In: Elias S, Simpson JL, eds. Maternal Serum Screening for Fetal Genetic Disorders. New York: Churchill Livingstone, 1992: 41–58. 19. Egelhoff JC, Prenger EC, Coley BD. The spine. In: Ball W Jr, ed. Pediatric Neuroradiology. Philadelphia: Lippincott-Raven, 1997:717–778. 20. Medina LS, Al-Orfali M, Zurakowski D, Poussaint TY, DiCanzio J, Barnes PD. Radiology 1999;211:767–771. 21. Appignani BA, Jaramillo D, Barnes PD, Poussaint TY. AJR 1994;163:1199–1203. 22. Raghavan N, Barkovich AJ, Edwards M, Norman D. AJR 1989;152:843–852. 23. Brophy JD, Sutton LN, Zimmerman RA, Bury E, Schut L. Neurosurgery 1989;25:336–340. 24. Moufarrij NE, Palmer JM, Hahn JF, Weinstein MA. Neurosurgery 1989;25: 341–346. 25. Milhorat TH, Miller JI. Neurosurgery. In: Avery GB, Fletcher MA, Mhairi GM, eds. Neonatology (4th ed). Philadelphia: JB Lippincott, 1994:1155–1163. 26. Volpe JJ. Neurology of the Newborn, 4th ed. Philadelphia: WB Saunders, 2001. 27. Hoffman HJ, Hendrick EB, Humphreys RP. Childs Brain 1976;2:145–155. 28. Hoffman HJ, Taecholarn C, Hendrick EB, Humphreys RP. J Neurosurg 1985;62:1–8. 29. Kriss VM, Desai NS. AJR 1998;171:1687–1692. 30. Medina LS, Crone K, Kuntz KM. Pediatrics 2001;108:E101. 31. Stirling AJ, Howel D, Millner PA, Sadiq S, Sharples D, Dickson RA. J Bone Joint Surg Am 1996;78(9):1330–1336. 32. Newton PO, Wenger DR. Idiopathic and congenital scoliosis. In: Morrissy RT, Weinstein SL, eds. Lovell & Winter’s Pediatric Orthopaedics, 5th ed. Philadel- phia: Lippincott Williams & Wilkins, 2000:677–740. 33. Rogala EJ, Drummond DS, Gurr J. J Bone Joint Surg Am 1978;60(2):173–176. 34. Al-Arjani AM, Al-Sebai MW, Al-Khawashki HM, Saadeddin MF. Saudi Med J 2000;21(6):554–557. 35. Weinstein SL. Spine 1999;24(24):2592–2600. 36. Weinstein SL, Ponseti IV. J Bone Joint Surg Am 1983;65(4):447–455. 37. Barnes PD, Brody JD, Jaramillo D, Akbar JU, Emans JB. Radiology 1993; 186(1):247–253. Chapter 18 Imaging of Spine Disorders in Children 349 38. Horton D, Barnes P, Pendleton BD, Polly M. J Okla State Med Assoc 1989; 82:15–19. 39. Rohrschneider WK, Forsting M, Darge K, Tröger J. Radiology 1996;200:383– 388. 40. Powell KR, Cherry JD, Hougen TJB, Blinderman EE, Dunn MC. J Pediatr 1975;87:744–750. 41. Byrd SE, Darling CF, McLone DG. Radiol Clin North Am 1991;29:711–752. 42. Estin MD, Cohen AR. Neurosurg Clin North Am 1995;6:377–391. 43. Herman TE, Oser RF, Shackelford GD. Clin Pediatr 1993;32:627–628. 44. Kaplan JO, Quencer RM. Radiology 1980;137:387–391. 45. McLone DG, Naidich TP. The tethered spinal cord. In: McLaurin RL, Schof L, Venes JL, Epstein F, eds. Surgery of the Developing Nervous System. Philadel- phia: WB Saunders, 1989:71–96. 46. Yamada S, Iacono RP, Andrade T, Mandybur G, Yamada BS. Neurosurg Clin North Am 1995;6:311–323. 47. Davis PC, Hoffman JC, Ball TI, et al. Radiology 1988;166:679–685. 48. Scatliff JH, Kendall BE, Kingsley DPE, Britton J, Grant DN, Hayward RD. AJNR 1989;10:269–277. 49. Pang D, Wilberger JE. J Neurosurg 1982;57:32–47. 50. Fone PD, Vapnek JM, Litwiller SE, et al. J Urol 1997;157. 51. Satar N, Bauer SB, Shefner J, Kelly MD, Darbey MM. J Urol 1995;154:754– 758. 52. Coley BD, Siegel MJ. Spinal ultrasonography. In: Siegel MJ, ed. Pediatric Sono- graphy. Philadelphia: Lippincott Williams & Wilkins, 2002:671–698. 53. Rubin JM, Di Pietro MA, Chandler WF, et al. Radiol Clin North Am 1988; 26:1–27. 54. Page LK. Occult spinal dysraphism and related disorders. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York: McGraw-Hill, 1992:2053–2058. 55. Westcott MA, Dynes MC, Remer EM, Donaldson JS, Dias LS. Radiographics 1992;12:1155–1173. 56. Atala A, Bauer SB, Dyro FM, et al. J Urol 1992;148:592–594. 57. Reigel DH, Tchernoukha K, Bazmi B, Kortyna R, Rotenstein D. Pediatr Neuro- surg 1994;20:30–42. 58. Law DA, Aronoff SC. Pediatr Infect Dis J 1992;11:968–971. 59. Rogg JM, Benzil DL, Haas RL, Knuckey NW. AJNR 1993;14:1393–1395. 60. DiTullio MV Jr. Surg Neurol 1977;7:351–354. 61. Feigen RD, Cherry JD. Textbook of Pediatric Infectious Diseases, 2nd ed. Philadelphia: WB Saunders, 1987. 62. Givner LB, Baker CJ. Pediatr Infec Dis J 1983;2:385–387. 63. Capitanucci ML, Iacobelli BD, Silveri M, Mosiello G, De Gennaro M. Eur J Pediatr Surg 1996;6(suppl 1):25–26. 64. Mills JL. Teratology 1982;25:385–394. 65. Rusnak SL, Discoll SG. Pediatrics 1965;35:989–995. 66. Becerra JE, Khoury MJ, Cordero JF, Ericson JD. Pediatrics 1990;85:1–9. 67. Long FR, Hunter JV, Mahboubi S, Kalmus A, Templeton JM. Tethered cord and associated vertebral anomalies in children and infants with imperforate anus: evaluation with MR imaging and plain radiography. Radiology 1996;200:3 77–382. 68. Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie GH. J Bone Joint Surg Am 1990;72(3):320–327. 69. Carman DL, Browne RH, Birch JG. J Bone Joint Surg Am 1990;72(3):328–333. 70. Shea KG, Stevens PM, Nelson M, Smith JT, Masters KS, Yandow S. Spine 1998; 23(5):551–555. 71. Loder RT, Urquhart A, Steen H, et al. J Bone Joint Surg Br 1995;77(5):768–770. 72. Crockett HC, Wright JM, Burke S, Boachie-Adjei O. Spine 1999;24(19): 2007–2009; discussion 2010. 73. Kalifa G, Charpak Y, Maccia C, et al. Pediatr Radiol 1998;28(7):557–561. 350 L.S. Medina et al. 74. Morin Doody M, Lonstein JE, Stovall M, Hacker DG, Luckyanov N, Land CE. Spine 2000;25(16):2052–2063. 75. Levy AR, Goldberg MS, Hanley JA, Mayo NE, Poitras B. Health Phys 1994; 66(6):621–633. 76. Levy AR, Goldberg MS, Mayo NE, Hanley JA, Poitras B. Spine 1996;21(13): 1540–1547; discussion 1548. 77. Goldberg MS, Mayo NE, Levy AR, Scott SC, Poitras B. Epidemiology 1998;9(3): 271–278. 78. Kalmar JA, Jones JP, Merritt CR. Spine 1994;19(7):818–823. 79. Kling TF Jr, Cohen MJ, Lindseth RE, De Rosa GP. Spine 1990;15(9):880–885. 80. Stringer DA, Cairns RA, Poskitt KJ, Bray H, Milner R, Kennedy B. Pediatr Radiol 1994;24(1):1–5. 81. Geijer H, Beckman K, Jonsson B, Andersson T, Persliden J. Radiology 2001;218(2):402–410. 82. Cheng JC, Guo X, Sher AH, Chan YL, Metreweli C. Spine 1999;24(16):1679–1684. 83. Barkovich AJ, Wippold FJ, Sherman JL, Citrin CM. AJNR 1986;7(5):795–799. 84. Elster AD, Chen MY. Radiology 1992;183(2):347–353. 85. Mikulis DJ, Diaz O, Egglin TK, Sanchez R. Radiology 1992;183(3):725–728. 86. Do T, Fras C, Burke S, Widmann RF, Rawlins B, Boachie-Adjei O. J Bone Joint Surg Am 2001;83–A(4):577–579. 87. Winter RB, Lonstein JE, Heithoff KB, Kirkham JA. Spine 1997;22(8):855–858. 88. Maiocco B, Deeney VF, Coulon R, Parks PF Jr. Spine 1997;22(21):2537–2541. 89. O’Brien MF, Lenke LG, Bridwell KH, Blanke K, Baldus C. Spine 1994; 19(14):1606–1610. 90. Prahinski JR, Polly DW Jr, McHale KA, Ellenbogen RG. J Pediatr Orthop 2000; 20(1):59–63. 91. Lewonowski K, King JD, Nelson MD. Spine 1992;17(6 suppl):S109–116. 92. Gupta P, Lenke LG, Bridwell KH. Spine 1998;23(2):206–210. 93. Schwend RM, Hennrikus W, Hall JE, Emans JB. J Bone Joint Surg Am 1995; 77(1):46–53. 94. Mejia EA, Hennrikus WL, Schwend RM, Emans JB. J Pediatr Orthop 1996; 16(3):354–358. 95. Weinberger E, Murakami J, Shaw D, White K, Radvilas M, Yean C. J Comput Assist Tomogr 1995;19:721–725. Chapter 18 Imaging of Spine Disorders in Children 351 19 Cardiac Evaluation: The Current Status of Outcomes-Based Imaging Andrew J. Bierhals and Pamela K. Woodard I. Does coronary artery calcification scoring predict outcome? II. Special case: high-risk patients III. Which patients should undergo coronary angiography? IV. Which patients should undergo noninvasive imaging of the heart? V. What is the appropriate use of coronary artery computed tomogra- phy and magnetic resonance? 352 Issues ᭿ A strong recommendation can be made for initial coronary angiogra- phy among high-risk patients and those who are post–myocardial infarction (MI) that was transmural or with ischemic symptoms (strong evidence). ᭿ A strong recommendation can be made for performing a noninvasive imaging examination [e.g., single photon emission computed tomo- graphy (SPECT) or stress echo] prior to coronary angiography in low-risk patients and those who have had a non–Q-wave MI (strong evidence). ᭿ Aside from coronary angiography, the appropriate usage of cardiac imaging studies remains unclear, and more research is required to evaluate the outcomes, as well as the cost-effectiveness of the afore- mentioned modalities (insufficient evidence). ᭿ Coronary artery calcium scoring has been shown in asymptomatic patients to be predictive of coronary artery disease; however, there have been no data to support the position of added predictive value over and above the clinical Framingham model (insufficient evidence). Key Points Definition and Pathophysiology The etiology of coronary artery disease (CAD) is multifactorial involving both interaction of lifestyle and genetic predispositions. While some factors are not modifiable, those risks that may be altered are often neglected until there evidence of disease. As a result, a multitude of tests and clinical Chapter 19 Cardiac Evaluation: The Current Status of Outcomes-Based Imaging 353 assessment tools have been developed to risk stratify patients in order to direct short- and long-term treatments. The modifiable risk factors (e.g., hypertension, hyperlipidemia, and diabetes) have been on the rise over the past decade (1,2); therefore, a greater urgency has arisen to identify patients with CAD. Coronary artery disease begins as fatty streaks in the coronary arteries that may begin as early as 3 years of age. The fatty streaks are composed of large cells with intracellular lipids (foam cells) that are located in the suben- dothelial region. As patients age, the fatty streaks develop into fibrous plaques that narrow the vessel lumen, reducing blood flow. The fibrous plaques over time may calcify, reducing vessel compliance and increasing fragility. This further reduces blood flow and increases the chance of the plaque rupturing, resulting in an acute coronary artery occlusion. Epidemiology Coronary artery disease is a nationwide epidemic involving 6.4% of the entire population (3,4) and is the largest cause of mortality, accounting for one in every five deaths (4). This translates into a death rate of 177.8 per 100,000 (based on 2001 estimates) (4). In the United States, over 1.5 million people will have a myocardial infarction, and the majority of the patients will initially present with symptoms in their 50s and 60s. A large volume of literature has been generated investigating these modalities, but little has focused on the impact the modalities have on the patient outcomes even though there has been a steady increase in the use of costly diagnostic testing and treatment (5). This chapter reviews the literature on the outcomes research of cardiac imaging, and makes recommendations concerning the utilization of the techniques in patient management. Overall Cost to Society In the United States, the estimated 2004 cost of heart disease to society is $238 billion, with over half secondary to CAD ($133 billion) (4,6). The cost of heart disease is substantial in comparison to other disease processes, such as cancers ($189 billion) and AIDS ($29 billion) (4,6). The costs of CAD include direct health care of $66 billion, and $67 billion in indirect costs (e.g., loss of productivity secondary to morbidity and mortality) (4,6). The expenditures for health care are consistently increasing, because of new technologies and the current medicolegal environment. An ever- declining budget results in a need for clinicians to incorporate cost- effective strategies in patient evaluations. However, cost-effective does not mean withholding evaluations or always ordering the seemingly least expensive test, but rather understanding what is most efficient with respect to a specific clinical situation, based on current research. The purpose of this approach is to direct a finite amount of resources and limit costs to society without affecting the quality of health care. This chapter reviews the cost-effectiveness and outcomes of various imaging modalities of heart disease, and makes recommendations concerning these techniques in patient care. Specifically, coronary artery calcification scoring, myocardial SPECT, angiography, stress echocardiography, and cardiac magnetic reso- [...]... Larosee K, et al Am J Cardiol 1996 ;78 :415–419 46 Nishimura T, Yamada N, Itoh A, et al AJR 1989;153 :72 1 72 4 47 Aurigemma G, Reichek N, Schiebler M, et al Am J Cardiol 1990;66:621–625 48 Boxt LM, Rozenshtein A Mag Reson Imaging Clin North Am 2003;11: 27 48 49 Fidler JL, Cheatham JP, Fletcher L, et al AJR 2000; 174 :355–359 50 Choi BW, Park YH, Choi JY, et al AJR 2001; 177 :1045–1049 51 Herzog C, Dogan S, Diebold... 2002;106:2 073 –2 077 21 Lipid Research Clinics Program JAMA 1984;251:365– 374 22 Qu W, Le TT, Azen ST, et al Diabetes Care 2003;26:905–910 23 Newman AB, Naydeck BL, Sutton-Tyrrell K, Feldman A, Edmundowicz D, Kuller L Circulation 2001;104:2 679 –2684 24 Sangiorgi G, Rumberger JA, Severson A, et al J Am Coll Cardiol 1998;31: 126–133 25 Janowitz WR, Agatston AS, Kaplan G, et al Am J Cardiol 1993 ;72 :2 47 254 26... Circulation 1995;91:54–65 27 Patterson RE, Eng C, Horowitz SF, Gorlin R, Goldstein SR J Am Coll Cardiol 1984;4: 278 –289 28 Garber AM, Solomon NA Ann Intern Med 1999;130 :71 9 72 8 29 Kuntz K, Tsevat J, Goldman L, Weinstein MC Circulation 1996;94:9 57 965 30 FRagmin and Fast Revascularisation during InStability in Coronary artery disease (FRISC II) Investigators Lancet 1999;354 :70 8 71 5 31 Cannon CP, Weintraub... 2001;344: 1 879 –18 87 32 Barnett PG, Chen S, Boden WE, et al Circulation 2002;105:680–684 33 Boden W, O’rourke R, Crawford M, et al N Engl J Med 1998;338: 178 5– 179 2 34 Pepine CJ, Allen HD, Bashore TM, et al J Am Coll Cardiol 1991;18:1149–1182 35 Ryan TJ, Anderson JL, Antman EM, et al J Am Coll Cardiol 1996;28:1328–1428 36 Kuntz K, Fleischmann KE, Hunick MGM, Douglas PS Ann Intern Med 1999; 130 :70 9 71 8 37 Hachamovich... survival (1.86 years) over a 2-year follow-up relative to immediate angiography (1 .76 years) Thus, conservative management (i.e., noninvasive image-directed angiography) is the dominant strategy over angiography in the non–Q-wave post-MI patient with resulting lower cost and improved outcome There is strong evidence to show that noninvasive testing prior to angiography is more cost-effective than angiography... the goal of imaging is to identify the level and extent of the stenosis or occlusion The optimal imaging strategy is somewhat dependent on the most likely method for intervention If a catheter-based intervention is likely, then a catheter-based imaging study is often warranted as the initial imaging study On the other hand, if a surgical intervention is likely, then a less invasive initial imaging study... of 87. 5% and specificity of 100% for diagnosing aortic occlusion, compared to catheter angiography (20) In a retrospective study of 45 patients with lower-limb ischemia at high risk for catheter angiography, none of 28 who subsequently underwent above-knee surgical reconstruc- 375 376 M.P Rosen tion required complementary catheter angiography However, in seven of 10 patients who underwent below-knee... 353–3 57 40 Udelson JE, Beshansky JR, Ballin DS, et al JAMA 288:2693– 270 0 3 67 368 A.J Bierhals and P.K Woodard 41 Hunink MGM, Kuntz K, Fleischmann KE, Brady TJ Ann Intern Med 1999;131: 673 –680 42 Hartnell G, Cerel A, Kamalesh M, et al AJR 1994;163:1061–10 67 43 Muzik O, Duvernoy C, Beanlands RS, et al J Am Coll Cardiol 1998;31:534–540 44 Wagner A, Mahrholdt H, Sechtem U, Kim R, Judd R Magn Reson Imaging. .. a noninvasive study) in a population with a non–Q-wave MI The results indicate a conservative management program is more cost-effective than immediate angiography in patients with a non–Q-wave MI In the acute setting, image-directed angiography resulted in a cost of $14 ,70 0 versus $19,200 for immediate angiography and persisted after 2 years of follow-up, at which time there was an approximate $2100... Current Status of Outcomes-Based Imaging Figure 19.4 Continued 361 362 A.J Bierhals and P.K Woodard Figure 19.5 Kaplan-Meier analysis of the probability of survival according to strategy group during 12 to 44 months of follow-up Death from any cause was included in this analysis The Cox proportional-hazards ratio for the conservative as compared with the invasive strategy was 0 .72 (95% confidence interval, . Neuroradiology. Philadelphia: Lippincott-Raven, 19 97: 7 17 77 8. 20. Medina LS, Al-Orfali M, Zurakowski D, Poussaint TY, DiCanzio J, Barnes PD. Radiology 1999;211 :76 7 77 1. 21. Appignani BA, Jaramillo D,. ed. Philadel- phia: Lippincott Williams & Wilkins, 2000: 677 74 0. 33. Rogala EJ, Drummond DS, Gurr J. J Bone Joint Surg Am 1 978 ;60(2): 173 – 176 . 34. Al-Arjani AM, Al-Sebai MW, Al-Khawashki HM,. 1998; 23(5):551–555. 71 . Loder RT, Urquhart A, Steen H, et al. J Bone Joint Surg Br 1995 ;77 (5) :76 8 77 0. 72 . Crockett HC, Wright JM, Burke S, Boachie-Adjei O. Spine 1999;24(19): 20 07 2009; discussion 2010. 73 .