Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

/pdf/2019-esc-guidelines-for-the-diagnosis-and-management-of-4aacwvv1mo.pdf

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS)

New @ESCardio Guidelines for the Diagnosis and Management of Acute #PulmonaryEmbolism developed in collaboration with @EuroRespSoc now available: #cardiotwitter @erspublicationshttp://bit.ly/2HnrJaj

https://erj.ersjournals.com/content/erj/early/2019/08/29/13993003.01647-2019.full.pdf

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) : The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)

ACS
: acute coronary syndrome
AMPLIFY
: Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-line Therapy
aPTT
: activated partial thromboplastin time
b.i.d.
: bis in diem (twice daily)
b.p.m.
: beats per minute
BNP
: brain natriuretic peptide
BP
: blood pressure
CI
: confidence interval
CO
: cardiac output
COPD
: chronic obstructive pulmonary disease
CPG
: Committee for Practice Guidelines
CRNM
: clinically relevant non-major
CT
: computed tomographic/tomogram
CTEPH
: chronic thromboembolic pulmonary hypertension
CUS
: compression venous ultrasonography
DSA
: digital subtraction angiography
DVT
: deep vein thrombosis
ELISA
: enzyme-linked immunosorbent assay
ESC
: European Society of Cardiology
H-FABP
: heart-type fatty acid-binding protein
HIT
: heparin-induced thrombocytopenia
HR
: hazard ratio
ICOPER
: International Cooperative Pulmonary Embolism Registry
ICRP
: International Commission on Radiological Protection
INR
: international normalized ratio
iPAH
: idiopathic pulmonary arterial hypertension
IVC
: inferior vena cava
LMWH
: low molecular weight heparin
LV
: left ventricle/left ventricular
MDCT
: multi-detector computed tomographic (angiography)
MRA
: magnetic resonance angiography
NGAL
: neutrophil gelatinase-associated lipocalin
NOAC(s)
: Non-vitamin K-dependent new oral anticoagulant(s)
NT-proBNP
: N-terminal pro-brain natriuretic peptide
o.d.
: omni die (every day)
OR
: odds ratio
PAH
: pulmonary arterial hypertension
PE
: pulmonary embolism
PEA
: pulmonary endarterectomy
PEITHO
: Pulmonary EmbolIsm THrOmbolysis trial
PESI
: pulmonary embolism severity index
PH
: pulmonary hypertension
PIOPED
: Prospective Investigation On Pulmonary Embolism Diagnosis
PVR
: pulmonary vascular resistance
RIETE
: Registro Informatizado de la Enfermedad Thromboembolica venosa
RR
: relative risk
rtPA
: recombinant tissue plasminogen activator
RV
: right ventricle/ventricular
SPECT
: single photon emission computed tomography
sPESI
: simplified pulmonary embolism severity index
TAPSE
: tricuspid annulus plane systolic excursion
Tc
: technetium
TOE
: transoesophageal echocardiography
TTR
: time in therapeutic range
TV
: tricuspid valve
UFH
: unfractionated heparin
V/Q scan
: ventilation–perfusion scintigraphy
VKA
: vitamin K antagonist(s)
VTE
: venous thromboembolism

Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

A great number of Guidelines have …

/pdf/2014-esc-guidelines-on-the-diagnosis-and-management-of-acute-1f9ulv0b8w.pdf

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

During the past decade, proof of the principle that peptide receptors can be used successfully for in vivo targeting of human cancers has been provided. The molecular basis for targeting rests on the in vitro observation that peptide receptors can be expressed in large quantities in certain tumors. The clinical impact is at the diagnostic level: in vivo receptor scintigraphy uses radiolabeled peptides for the localization of tumors and their metastases. It is also at the therapeutic level: peptide receptor radiotherapy of tumors emerges as a serious treatment option. Peptides linked to cytotoxic agents are also considered for therapeutic applications. The use of nonradiolabeled, noncytotoxic peptide analogs for long-term antiproliferative treatment of tumors appears promising for only a few tumor types, whereas the symptomatic treatment of neuroendocrine tumors by somatostatin analogs is clearly successful. The present review summarizes and critically evaluates the in vitro data on peptide and peptide receptor expression in human cancers. These data are considered to be the molecular basis for peptide receptor targeting of tumors. The paradigmatic peptide somatostatin and its receptors are extensively reviewed in the light of in vivo targeting of neuroendocrine tumors. The role of the more recently described targeting peptides vasoactive intestinal peptide, gastrin-releasing peptide, and cholecystokinin/gastrin is discussed. Other emerging and promising peptides and their respective receptors, including neurotensin, substance P, and neuropeptide Y, are introduced. This information relates to established and potential clinical applications in oncology.

/pdf/peptide-receptors-as-molecular-targets-for-cancer-diagnosis-43jzca3l3a.pdf

Peptide receptors as molecular targets for cancer diagnosis and therapy.

Commercially available software for cardiovascular image analysis often has limited functionality and frequently lacks the careful validation that is required for clinical studies. We have already implemented a cardiovascular image analysis software package and released it as freeware for the research community. However, it was distributed as a stand-alone application and other researchers could not extend it by writing their own custom image analysis algorithms. We believe that the work required to make a clinically applicable prototype can be reduced by making the software extensible, so that researchers can develop their own modules or improvements. Such an initiative might then serve as a bridge between image analysis research and cardiovascular research. The aim of this article is therefore to present the design and validation of a cardiovascular image analysis software package (Segment) and to announce its release in a source code format. Segment can be used for image analysis in magnetic resonance imaging (MRI), computed tomography (CT), single photon emission computed tomography (SPECT) and positron emission tomography (PET). Some of its main features include loading of DICOM images from all major scanner vendors, simultaneous display of multiple image stacks and plane intersections, automated segmentation of the left ventricle, quantification of MRI flow, tools for manual and general object segmentation, quantitative regional wall motion analysis, myocardial viability analysis and image fusion tools. Here we present an overview of the validation results and validation procedures for the functionality of the software. We describe a technique to ensure continued accuracy and validity of the software by implementing and using a test script that tests the functionality of the software and validates the output. The software has been made freely available for research purposes in a source code format on the project home page http://segment.heiberg.se
 . Segment is a well-validated comprehensive software package for cardiovascular image analysis. It is freely available for research purposes provided that relevant original research publications related to the software are cited.

/pdf/design-and-validation-of-segment-freely-available-software-40iwqqksv9.pdf

Design and validation of Segment--freely available software for cardiovascular image analysis.

Lung scintigraphy is the primary tool for diagnostics of pulmonary embolism. A perfusion study is often complemented by a ventilation study. Intermediate probability scans are frequent. Our goal was to develop a fast method for tomographic ventilation and perfusion scintigraphy to improve the diagnostic value of lung scintigraphy. METHODS: SPECT was performed with a dual-head gamma camera. Acquisition parameters were determined using a thorax phantom. Ventilation tomography after inhalation of 30 MBq (99m)Tc-diethylenetriaminepentaacetate (DTPA) aerosol was, without patient movement, followed by perfusion tomography after an intravenous injection of 100 MBq (99m)Tc-labeled macroaggregated albumin (MAA). Total SPECT acquisition time was 20 min. (99m)Tc-DTPA clearance, calculated from initial and final SPECT projections, was used for correction of the ventilation projection set before iterative reconstruction of ventilation and perfusion. The ventilation background was subtracted from the perfusion tomograms. A normalized ventilation/perfusion quotient (V/P quotient) image set was calculated. The method was evaluated on a trial group of 15 patients. RESULTS: Ventilation and perfusion images had adequate quality and showed ventilation/perfusion (V/Q quotient) relationships more clearly than did planar images. Frontal and sagittal slices were superior to planar scintigraphy for characterization of embolized areas. The V/Q quotient was supportive, particularly in the patients with chronic obstructive pulmonary disease. CONCLUSION: Fast, high-quality, ventilation/perfusion SPECT with standard isotopes doses is feasible and may contribute to higher objectivity in evaluating lung embolism as well as other lung diseases. The costs for the procedure and patient care until diagnosis are low because of the comprehensive system for the study and, particularly, the short time for its completion.

https://jnm.snmjournals.org/content/jnumed/42/8/1288.full.pdf

Comprehensive Ventilation/Perfusion SPECT

Summary Planar lung ventilation/perfusion scintigraphy (V/PPLANAR) is a standard method for diagnosis of pulmonary embolism (PE). The goals of this study were to test whether the diagnostic information of ventilation/perfusion tomography (V/PSPET) applied in clinical routine might enhance information compared with V/PPLANAR and to streamline data processing for the demands of clinical routine. This prospective study includes 53 patients suspected for PE referred for lung scintigraphy. After inhalation of 99m Tc-DTPA planar ventilation imaging was followed by tomography, using a dual-head gamma camera. 99m Tc-MAA was injected i.v. for perfusion tomography followed by planar imaging. Patients were examined in supine position, unchanged during V/P tomography. Two reviewers evaluated V/PPLANAR and V/PSPET images separately and randomly. Mismatch points were calculated on the basis of extension of perfusion defects with preserved ventilation. Patients were followed up clinically for at least 6 months. With V/PSPET the number of patients with PE was higher and 53% more mismatch points were found. In V/PSPET interobserver variation was less compared with V/PPLANAR. Ancillary findings were observed by both techniques in half of the patients but more precisely interpreted with V/PSPET. V/PSPET shows more and better delineated mismatch defects, improved quantification and less interobserver variation compared with V/PPLANAR. V/PSPET is amenable to implementation for clinical routine and suitable even when there is demand for a high patient throughput.

/pdf/diagnostic-evaluation-of-planar-and-tomographic-ventilation-4vt6czuq06.pdf

Diagnostic evaluation of planar and tomographic ventilation/perfusion lung images in patients with suspected pulmonary emboli

Planar lung scintigraphy is a standard method used for the diagnosis of lung embolism, but it is hampered by the high incidence of nondiagnostic tests. Ventilation/perfusion SPECT may possibly improve this situation. The objective of this study was to compare planar lung scintigraphy with ventilation/perfusion SPECT using pigs with artificially engendered lung emboli labeled with (201)Tl. METHODS: Sixteen anesthetized pigs were each injected with zero to 4 latex emboli. Cylindric emboli were used in the first 7 pigs and flat 3-tailed emboli were used in the remaining 9 pigs. The pigs spontaneously inhaled 30 MBq (99m)Tc-diethylenetriaminepentaacetic acid aerosol for ventilation scintigraphy. Planar scintigraphy and SPECT were performed using a double-head gamma camera in (99m)Tc and (201)Tl windows. Immediately thereafter, 100 MBq (99m)Tc-labeled macroaggregated albumin were injected intravenously followed by SPECT and, finally, planar scintigraphy. The ventilation background was subtracted from the perfusion tomograms for calculation of a normalized ventilation/perfusion (V/P) quotient image set. RESULTS: The cylindric emboli caused artifacts in the ventilation images; therefore, these were excluded from the final analysis. However, for the planar perfusion images of these pigs, sensitivity and specificity were 71% and 91%, respectively, whereas SPECT yielded 100% for both. For the 3-tailed emboli and ventilation/perfusion images, the sensitivity and specificity were 64% and 79%, respectively, for the planar modality, whereas SPECT yielded values of 91% and 87%, respectively. CONCLUSION: V/P SPECT may improve the diagnostic power of lung scintigraphy. (Less)

http://jnm.snmjournals.org/content/43/5/640.full.pdf

Lung Ventilation/Perfusion SPECT in the Artificially Embolized Pig

UNLABELLED In a recent study, artificial neural networks were trained to detect coronary artery disease using scintigraphic data as input. The performance of the networks was better than that of human experts using coronary angiography as a gold standard. In clinical practice, this type of neural networks will not take over the decision-making process from the physician but will assist by proposing an interpretation of the scintigram. The purpose of this study was to assess the influence of such decision support on the interpretations of the physicians. METHODS A population of 135 patients who had undergone both myocardial 99mTc-sestamibi rest/stress scintigraphy and coronary angiography within a 3-mo period was studied. An image set consisting of the bull's-eye rest, stress, difference and quote images was constructed for each patient. Three experienced physicians independently classified all image sets regarding the presence and/or absence of coronary artery disease in two vascular territories using a four-grade scale. The physicians classified the image sets twice with and twice without the advice of artificial neural networks. RESULTS The joint evaluation of the three physicians showed significantly improved performance with decision support, measured as increases in the areas under the receiver operating characteristic curves from 0.65 to 0.70 (P = 0.018) and from 0.79 to 0.82 (P = 0.006) for two vascular territories. Furthermore, the joint evaluation showed significantly less intraobserver and interobserver variability with decision support. CONCLUSION Physicians classifying myocardial bull's-eye images benefit from the advice of artificial neural networks. These results show the high potential for neural networks as clinical decision support systems.

https://jnm.snmjournals.org/content/40/1/96.full.pdf

Improved classifications of myocardial bull's-eye scintigrams with computer-based decision support system.

The purpose of this study was to develop a computer-based method for automatic detection and localization of coronary artery disease (CAD) in myocardial bull's-eye scintigrams. Methods: A population of 135 patients who had undergone both myocardial 99mTc-sestamibi rest-stress scintigraphy and coronary angiography within 3 mo was studied. Different image data reduction methods, including pixel averaging and two-dimensional Fourier transform, were applied to the bull's-eye scintigrams. After a quantitative and qualitative evaluation of these methods, 30 Fourier components were chosen as inputs to multilayer perceptron artificial neural networks. The networks were trained to detect CAD in two vascular territories, using coronary angiography as gold standard. A 'leave one out' procedure was used for training and evaluation. The performance of the networks was compared to those of two human experts. Results: One of the human experts detected CAD in one of two vascular territories, with a sensitivity of 54.4% at a specificity of 70.5%. The sensitivity of the networks was significantly higher at that level of specificity (77.2%, p = 0.0022). The other expert had a sensitivity of 63.2% at a specificity of 61.5%. The networks had a sensitivity of 77.2% (p = 0.038) at this specificity level as well. The differences in sensitivity between human experts and networks for the other vascular territory were all less than 6% and were not statistically significant. Conclusion: Artificial neural networks can detect CAD in myocardial bull's-eye scintigrams with such a high accuracy that the application of neural networks as clinical decision support tools appears to have significant potential. (Less)

/pdf/automated-interpretation-of-myocardial-spect-perfusion-4192yjdz6k.pdf

Automated Interpretation of Myocardial SPECT Perfusion Images Using Artificial Neural Networks

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