Discussion: Cardiac and Pulmonary Modules
Discussion: Cardiac and Pulmonary Modules
Discussion: Cardiac and Pulmonary Modules
The Case Study includes content from the Diabetes, Renal, Cardiac and Pulmonary Modules. Please answer all of the questions within the case study with comprehensive answers. You need to include at minimum two references: one can be your textbook and the other is your choice whether it be an article or another textbook. You must include in text citations as well as a reference list. Both should be in APA format.
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Abstract
Background
Pulmonary nodules (PN) are frequently detected incidentally during coronary computed tomography angiography (CTA). We evaluated whether the 2017 Fleischner Society guidelines may result in a decrease of follow-up testing of incidental PN as compared to prior guidelines in patients undergoing coronary CTA.
Methods
We conducted a retrospective study of a registry of emergency department patients who underwent coronary CTA for acute coronary syndrome assessment between 2012 and 2017. Based on guidelines, patients <35 years, history of cancer, or prior exams showing stability of PN were excluded. Patients >60 years, history of smoking, irregular/spiculated PN morphology, or PN size >20mm were classified as high-risk for lung cancer. Radiological findings pertaining to PN were identified (PN size, morphology, quantity) through review of radiology reports. PN follow-up recommendations were established using 2017 Fleischner Society Guidelines and compared with prior guidelines for solid (2005) and subsolid (2013) PN. Data were analyzed with Student’s t-test.
Results
The registry included 2,066 patients (female 45.1%, 52.9±11.0 years), of which 578 (28.0%) reported PN. 438 of those (21.2%) were eligible for guideline-based follow-up evaluation. 205 (4 6.8%) were classified as high-risk for lung cancer. 2017 guidelines reduced the number of individuals requiring follow-up by 64.5%, from 264 (12.8%) to 94 patients (4.5%) when compared to prior guidelines (p<0.001). The minimum number of follow-up chest CTs decreased by 55.8% from 430 to 190 (p<0.001).
Conclusion
Application of the 2017 Fleischner Society Guidelines resulted in a significant decrease of follow-up testing for incidental PN in patients undergoing coronary CTA for suspected acute coronary syndrome.
Introduction
Coronary computed tomography angiography (CTA) has become an alternative to functional testing for patients presenting to the emergency department with acute chest pain and low to intermediate risk for acute coronary syndrome (ACS)1–3. Coronary CTA datasets not only provide visualization of cardiac anatomy, but also non-cardiac anatomy including the lower parts of the lungs below the level of carina, mediastinum, bones, and the upper parts of the abdomen4. Thus, extra-cardiac incidental findings are common5–11, the majority being pulmonary nodules (PN) with a prevalence of 16-23%12, 13. Those extra-cardiac findings result in a substantial number of additional downstream tests, especially follow-up chest CTs.
Recommendations for follow-up of solid PN were widely standardized by the 2005 Fleischner Society Guidelines for the management of incidental lung nodules and later for subsolid PN by additional 2013 guidelines14, 15. Guideline-based PN follow-up substantially increases costs in patients with CTA-based, anatomic testing of acute and chronic chest pain, but has shown to result in only a minimal reduction in mortality from lung cancer and is only cost-effective in smokers, but not in non-smokers5, 8, 12, 16.
In 2017, the Fleischner Society updated their guidelines recommending follow-up testing in patients with an estimated risk for lung cancer of 1% or greater17. Calculation of lung cancer risk was determined by PN characteristics such as size, location, and morphology, but also by clinical risk factors such as age, smoking history, and exposure to toxic substances. The highest impact on the number of patients with follow-up recommendations might be the increased threshold for solid PN follow-ups from 5 mm (2005 guidelines) to 6mm in the 2017 guidelines, below which a follow-up is not recommended. Also, while all patients with high risk for lung cancer received recommendations for follow-up chest CT per 2005 guidelines, patients with high risk for lung cancer, but solid PN <6 mm would not get follow-up per 2017 guidelines.
The aim of our study was to compare the number of patients with need for follow-up testing per revised 2017 Fleischner Society Guidelines for management of incidental PN versus the relevant prior applicable guidelines (2005 guidelines for solid PN, and 2013 guidelines for subsolid PN) in patients with acute chest pain who underwent coronary CTA for ACS assessment.
Materials and Methods
Subjects
This retrospective, IRB-approved and HIPPA-compliant study was conducted using a prospectively acquired registry which included 2,066 emergency department patients (52.9 ± 11.0 years; 45.1% female), who underwent coronary CTA for ACS assessment in a tertiary, academic hospital from 2012 to 2017. The registry’s inclusion criteria for ACS assessment by coronary CTA were summarized previously18, in a manuscript that dealt with the efficiency and safety of implementation of coronary CTA in the emergency department, but not related to incidental findings (and reporting only 1,022 of 2,066 patients included in the present study)18.
Coronary CT angiography
All coronary CTA scans were performed on second- and third-generation dual-source CT scanners (Siemens Somatom Flash and Siemens Somatom Force, Siemens Healthineers, Forchheim, Germany) and described in above mentioned manuscript18. Based on the scout, the scan length was set from the carina to the diaphragm covering the heart, but not the entire lungs or was tailored based on the Calcium scan images. To visualize the lungs, an image series with a maximum field of view covering the lungs over the entire scan length were reconstructed with 1.5 mm slice thickness in addition to image series with a field of view tailored to the heart. Image quality (but not incidental findings) between second- and third-generation dual-source CT scanners was reported in a subset of 246 patients19.
Pulmonary nodule assessment
PN evaluation was mandatory as part of the structured coronary CTA report and confirmed by two board-certified radiologists specialized on cardiac imaging. PN were measured in long and short axis and an averaged diameter rounded to the nearest millimeter was noted in the report (Figure 1). All radiology reports were extracted from our Research Electronic Data Capture (RedCap, Harvard Catalyst, Boston, Massachusetts) and further evaluated using Microsoft Excel (Microsoft Corporation, Redmond, Washington). Reports were screened for PN evaluation by a cardiac imaging fellow (J.S.). In cases where the radiology report did not clearly describe PN characteristics (type, morphology, size, quantity), images were reviewed by a board-certified radiologist using dedicated picture archiving and communication system (PACS) software (AGFA Impax 6.6.1.3004, AGFA, Mortsel, Belgium).
Textbook Referrenc:
1. Huether, S. E., & McCance, K. L., (2017). Understanding Pathophysiology (6th ed.) St. Louis: Mosby: 978-0-323354097
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