A wet mount should be performed to rule out will direct the workup for this diagnosis generic suhagra 100 mg online impotence merriam webster. Refer to a derma- Other tologist or gynecologist for treatment of warts of the Medications suhagra 100 mg generic erectile dysfunction treatment prostate cancer. Tamoxifen, which acts as an younger than 12 months do not have the coordination antiestrogen on breast tissue, has estrogenic effects on to insert anything into their vagina; suspect child abuse the endometrium and can cause endometrial hyperpla- in those cases and inspect for bruising or excoriations. Mahoney S, Parker C, Potlog-Nahari C, et al: Abnormal uterine Casablanca Y: Management of dysfunctional uterine bleeding, bleeding: A primary care primer, Consultant 46:225, 2006. Postmenopausal women often have Characteristics of Discharge discharge related to atrophic vaginitis, caused by the Copious amounts of greenish, offensive-smelling defciency of estrogen in the vaginal tissues. Mu- Vulvar itching, burning, and a foul odor often copurulent or purulent discharges are associated with accompany vaginal discharge. A moderate amount of pinworms, and genital warts (condylomata acumi- white, curdlike discharge is consistent with candida nata) can all cause itching. Microscopic examination of the vaginal their hypoestrogenic state and their perineal hygiene, discharge is more sensitive than the clinical picture in which is often poor. The postmenopausal woman may experience these same Itching, Swelling, and Redness symptoms with estrogen defciency. Chemical vagi- Vaginitis causes infammation of the tissues, resulting in nitis in a young girl is usually caused by sensitivity erythema and edema. Because of the infammatory pro- to bubble bath, whereas in the adolescent or woman cess, the amount of discharge will produce a concomitant it occurs because of the use of scented douches, amount of swelling and redness of the vulva and vagina. Scratch- In childhood and adolescence, reports of vulvar ing can lead to excoriations and satellite lesions. A, Clue cells (epithelial cells with clumps of bacteria) are evident in bacterial vaginosis. Odor commonly accompanies trichomonal infec- children but can be transmitted to the neonate from an tions. Recent Treatment for a Sexually Transmitted Infection Is this likely a sexually transmitted infection? How often do typically notice them on the external labia and report you use protection? Typically, condylomata acuminata (genital warts) are rough, ver- Sexual History rucous lesions that are usually located inferiorly from Early-age onset of sexual activity, multiple partners, the fossa navicularis to the fourchette and perineal and nonuse of barrier contraceptives, particularly area. A painless ulcer suggests syphilis and classically condoms, increase the risk of vaginal infection. However, there can are common in women of childbearing age (12 to be more than one chancre, especially if the patient is 50 years) who have acquired a new partner, but the immunocompromised. Activities l Are you taking antibiotics, hormones, or oral contra- Riding a bicycle, using pools or hot tubs, or wearing ceptive pills? Premenarche Girls who have not yet reached menarche are prone to Immunocompromised States vulvovaginal infections because of a nonestrogenized Refractory fungal vulvovaginitis may indicate undiag- vagina and the lack of labial development and hair nosed diabetes or an immunocompromised state. Birth control pills, corticosteroids, antibiotics, and l Have you ever had these symptoms before? Oral contraceptives can alter the vaginal pH, and l Are the episodes related to any particular activity or antibiotics can alter the normal vaginal fora; both time? Corticosteroids and chemotherapy can produce an immunocompromised Chronology of Symptoms state and provide the opportunity for fungal infection. Symptoms associated with use of condoms or Pinworms are intestinal parasites that inhabit the spermicidal jelly suggest sensitivity to the product. If rectum or colon and emerge to lay eggs in the skin- the discharge occurs monthly with worsening after folds of the anus. Perianal pruritus, especially menses, suspect a chronic condition, such as vulvo- at night, along with pain or itching of genitals is vaginitis candidiasis. Possible infection reservoirs are oral and anal cavities, Key Questions which may need to be cultured for herpes or gonor- l Have you been tested and treated for this condition rhea. Yeast grows best in areas that are comitant vaginal infection may have been missed. Oral contracep- especially with the over-the-counter medicines for tives, hormone replacement therapy, antibiotics (e. Women may stop us- ing vaginal medications when menses begins and resume What are other possible causes for this vaginitis? They may also discontinue the medication early, as soon as symptom relief occurs, or if they have a Key Questions drug side effect (e. Hygiene Practices Key Questions Feminine hygiene practices can contribute to vaginitis l Have any family members or sexual partners re- by causing a local allergic reaction, altered vaginal ported itching, rashes, sores, lumps, or bumps with fora, or contamination of the vagina from the rectum. Do you have Perfumes in douches, sprays, lubricants, and bubble a new or untreated partner? Transmission Douching Caregivers, parents, and siblings can spread infections, Frequent douching can change the balance of normal such as candidiasis, molluscum contagiosum, herpes, vaginal fora by altering the pH. This allows recoloni- lice, and pinworms to children through poor hygiene zation of the vagina with enteric bacteria, leading to practices. Douching can cause an allergic for herpes, genital warts, and molluscum contagiosum. Colored or perfumed toilet paper can irritate the perineum, causing redness and itching. Wiping New or Untreated Partner with tissue after urination or defecation in the direction The most common cause of reinfection is intercourse from the anus toward the vagina can inoculate the with a new or untreated partner. Fever is uncommon with child who puts a foreign object into her vagina may vaginitis. Foreign bodies in the vagina are associ- Perform an Oral Examination ated with vaginal bleeding or spotting. If the object Oral thrush may accompany vulvar candidiasis, par- is left for some time, it can imbed and perforate the ticularly in children. Perform an External Genitalia Examination Are there any associated symptoms that point to a cause? Palpate for inguinal lymphadenopathy and tenderness, which can be present with vaginal infections. Inspect Key Questions the vulva and labia, looking for erythema, excoriations, l Do you have burning or pain with urination? The skin is often bright red and swollen have urinary frequency or hesitation or nighttime with small fssures or excoriations from candidiasis. Palpate Bartholin and Skene glands and l If an infant: Does the infant have a cough? If purulent discharge Urinary Tract Symptoms is seen, consider the diagnoses of gonorrhea or chla- Atrophic vaginitis is often accompanied by dysuria, mydia and obtain specimens for diagnostic tests. Estrogen defciency Condylomata lata, condylomata acuminata, and affects the woman’s entire lower genital tract and may molluscum contagiosum are all papular lesions found produce symptoms that can be confused with a urinary on the labia, perineum, and anal regions.

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Consider pericardiocentesis or pericardial window under local anesthesia prior to induction order discount suhagra erectile dysfunction causes natural cures, as drainage of even a small amount of fluid may improve the patient’s status dramatically order suhagra 100mg amex erectile dysfunction filthy frank lyrics. The considerable manipulation of the heart, extensive dissection, blood loss, dysrhythmias, and unrelieved tamponade make pericardiectomy cases a challenge. Suggested Viewing Links are available online to the following videos: Bypass Surgery on a Beating Heart. Challenges of off-pump coronary revascularization include accurate vascular anastomosis while minimizing hemodynamic perturbations during the procedure. Interrupting flow to the target artery can → regional ischemia, arrhythmias, and hemodynamic instability; displacing the heart to expose lateral or posterior arteries may → ventricular compression and profound hemodynamic compromise. Although not fully defined, ischemic preconditioning results from exposure to transient myocardial ischemia and is an endogenous adaptation that may mitigate the effects of subsequent prolonged myocardial ischemia. Thus, mechanically occluding the coronary artery for a brief period may confer some protection from ischemic injury associated with coronary occlusion during the anastomosis. Important preop considerations include the number and suitability of distal-target coronary arteries, cardiac and pulmonary status, and other medical comorbidities. The presence of cardiomegaly may limit the degree of intraop cardiac manipulation. Occasionally, placement of intraaortic balloon pump intraop may facilitate the off-pump approach in a patient with ischemic cardiomyopathy. The patient is partially heparinized, and an intravenous bolus of lidocaine is given. If vein grafts are used, the proximal anastomoses may be performed at this point or later, after the completion of the distal anastomoses, using a partial side- biting aortic cross-clamp or automated anastomotic device. The goal of the operation is to establish adequate perfusion of the most critical vascular bed first. Mechanical coronary artery stabilizers, based on local myocardial compression (Fig. After stabilization, the artery is occluded (following a period of ischemic preconditioning), and an arteriotomy is made. The patient is monitored closely at this point for any signs of myocardial ischemia and/or hemodynamic instability. To expose the lateral and posterior target vessels, manipulation of the heart is necessary and may not be well tolerated. During lateral and posterior pericardial suture placement, the surgeon displaces and compresses the heart, resulting in temporary hemodynamic compromise. Additional exposure techniques include the use of an apical suction device to facilitate cardiac manipulation with potentially less hemodynamic compromise, Trendelenburg position and tilting the operating table to the right, release of right pericardial stay sutures, opening of the right pleura, and incising the right pericardium, and placement of laparotomy sponges. The target vessel is stabilized again, ischemic preconditioning is carried out, and the artery is opened. After construction of the distal anastomosis, the graft is relieved of any residual air before securing the sutures and the proximal anastomosis performed if not already done so as noted earlier. Variations in coronary artery bypass and valvular heart surgery, with minimally invasive techniques. It is important to know the coronary artery anatomy and the planned surgical procedure and sequence. For example, proximal surgical occlusion of a coronary artery with high-grade distal disease may be poorly tolerated as compared with severe proximal disease with collateralization. Positioning of the heart for access to the target vessel, as well as mechanical stabilization of the heart to immobilize the vessel for accurate anastomosis tend to produce hemodynamic compromise. Snares may be placed around the coronary target vessel to create a dry operative field; however, this may provoke regional ischemia. Rajakaruna C, Rogers C, Pike K, et al: Superior haemodynamic stability during off-pump coronary surgery with thoracic epidural anaesthesia: results from a prospective randomized controlled trial. Roosens C, Heerman J, De Somer F, et al: Effects of off-pump coronary surgery on the mechanics of the respiratory system, lung, and chest wall: comparison with extracorporeal circulation. Straka Z, Brucek P, Vanek T, et al: Routine immediate extubation for off-pump coronary artery bypass grafting without thoracic epidural analgesia. The development of less-invasive surgery has resulted in alternative and novel approaches to cardiac surgery, including port-access cardiac surgery and off-pump coronary revascularization. The port-access approach was developed in the mid- 1990s and is used less frequently in the current setting because of its complexity. With the development of robotic (or total endoscopic) techniques, the port-access technology is being employed as a means to achieve cardiopulmonary bypass and cardioplegic arrest. The femoral artery is cannulated with a 19–23 Fr Y-shaped cannula, which permits arterial inflow and insertion of the endoaortic clamp. Venous drainage is provided by the 22–25 Fr cannula, introduced through a femoral vein. Drainage may be augmented by 20–40%, using vacuum-assisted venous drainage or a centrifugal venous drainage pump placed between the venous cannula and the reservoir. The lumen used for balloon inflation is connected to a manometer to monitor balloon pressure. Cardioplegic solution is delivered through a central lumen, which also acts as an aortic root vent after cardioplegia delivery. Exposure of the lateral and posterior aspects of the heart is easily accomplished in the arrested heart, thereby permitting two- and three-vessel coronary revascularization. The endoaortic balloon occlusion catheter is inflated in the ascending aorta, and antegrade cardioplegia is delivered through the central lumen. Bonatti J, Schachner T, Bonaros N, et al: Technical challenges in totally endoscopic robotic coronary artery bypass grafting. Dogan S, Graubitz K, Aybek T, et al: How safe is the port access technique in minimally invasive coronary artery bypass grafting? Maselli D, Pizio R, Borelli G, et al: Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli. Because of the progress in video-assisted surgery, a less-invasive approach to cardiac surgery has been developed, and various techniques of mitral valve surgery through limited thoracotomy or upper sternotomy incisions and a port-access technique to achieve cardioplegic arrest are now used in the clinical setting. Limited thoracotomy: The right thoracotomy incision is a less-invasive approach (compared to median sternotomy) for mitral valve procedures (Fig. Utilizing hypothermic fibrillatory or cardioplegic arrest, the mitral valve, annulus, and subvalvular apparatus can be visualized directly and the valve procedure carried out. The right thoracotomy approach with left atriotomy and exposure of the mitral valve area with prosthetic valve in place. An external aortic cross-clamp is introduced through a separate incision in the chest. After achieving cardioplegic arrest, the mitral valve is replaced with thoracoscopic assistance. Proposed advantages of the micro-mitral approach include the avoidance of a sternotomy, with decreased chest-wall trauma and patient discomfort. An alternative partial sternotomy approach to mitral and aortic valve surgery has been described.

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In epicardial arteries the vasodilator response is similar to nitroglycerin and is effective in preventing coronary vasospasm superimposed on a coronary stenosis generic suhagra 100 mg on line erectile dysfunction tumblr, as well as in normal arteries of patients with variant angina order 100mg suhagra amex homemade erectile dysfunction pump. Calcium channel blockers also submaximally vasodilate coronary resistance vessels. In this regard, dihydropyridine derivatives such as nifedipine are particularly potent and can sometimes precipitate subendocardial ischemia in the presence of a critical stenosis. This arises from a transmural redistribution of blood flow (coronary steal) as well as the tachycardia and hypotension that transiently occur with short half-life formulations of nifedipine. Experimentally, a differential sensitivity of the microcirculation to adenosine is observed, with the direct 3,4 effects related to resistance vessel size and restricted primarily to vessels smaller than 100 µm. These agents 7 circumvent the need for continuous infusions during myocardial perfusion imaging (see Chapter 16). Dipyridamole produces vasodilation by inhibiting the myocyte reuptake of adenosine released from cardiac myocytes. It therefore has actions and mechanisms similar to those of adenosine, with the exception that the vasodilation is more prolonged. It can be reversed with the administration of the nonspecific adenosine receptor blocker aminophylline. Papaverine is a short-acting coronary vasodilator that was the first agent used for intracoronary vasodilation. After bolus injection, it has a rapid onset of action, but the vasodilation is more prolonged than after adenosine (approximately 2 minutes). In fact, individual coronary resistance arteries are a longitudinally distributed network, and in vivo studies of the coronary microcirculation have demonstrated considerable spatial heterogeneity of specific 3,4,6 resistance vessel control mechanisms (Fig. Each resistance vessel needs to dilate in an orchestrated fashion to meet the needs of the downstream vascular bed, which is frequently removed from the site of metabolic control of coronary resistance. This can be accomplished independently of metabolic signals by sensing physical forces such as intraluminal flow (shear stress–mediated control) or intraluminal pressure changes (myogenic control). Epicardial arteries (>400 µm in diameter) serve a conduit artery function, with diameter primarily regulated by shear stress, and contribute minimal pressure drop (<5%) over a wide range of coronary flow. Coronary arterial resistance vessels can be divided into small arteries (100 to 400 µm), which regulate their tone in response to local shear stress and luminal pressure changes (myogenic response), and arterioles (<100 µm), which are sensitive to changes in local tissue metabolism and directly control perfusion of the low-resistance coronary capillary 3,4 2 bed (Fig. Capillary density of the myocardium averages 3500/mm (resulting in average intercapillary distance of 17 µm), which is greater in the subendocardium than in the subepicardium. The epicardial conduit arteries arborize into subepicardial and subendocardial resistance arteries. Intramural penetrating resistance arteries are unique in that they are removed from subendocardial metabolic stimuli and theoretically are more dependent on regulating their tone in response to shear stress and luminal pressure as mechanisms to produce dilation in response to changes in metabolism of the distal subendocardial arteriolar plexus. Regulation of coronary vasomotor tone under normal conditions and during acute myocardial hypoperfusion. Small distal arterioles immediately before the capillaries are sensitive to tissue metabolites. Upstream intermediate arterioles are pressure sensitive, with myogenic mechanisms predominating. Small resistance arteries are removed from the metabolic milieu and primarily adjust local tone in response to shear stress and flow. A, Under resting conditions, most of the pressure drop to flow arises from small arteries and arterioles. After dipyridamole vasodilation, a redistribution of microcirculatory resistance is seen, with a greater pressure drop occurring across small arteries and postcapillary venules that do not alter their resistance. A reduction in pressure to 38 mm Hg elicited dilation in arterioles smaller than 100 µm, whereas larger arteries tended to constrict passively from the reduction in distending pressure. C, Homogeneous vasodilation of resistance arteries during increases in myocardial oxygen consumption. Dilation occurs in all microvascular resistance arteries, being greatest in vessels smaller than 100 µm. Heterogeneous changes in epimyocardial microvascular size during graded coronary stenosis: evidence of the microvascular site for autoregulation. Comparison of the effects of increased myocardial oxygen consumption and adenosine on the coronary microvascular resistance. After pharmacologic vasodilation with dipyridamole, resistance artery vasodilation attenuates the precapillary pressure drop in arterial resistance vessels. At the same time, there is an increased pressure drop and redistribution of resistance to venular vessels, in which smooth muscle relaxation is limited and the already low resistance is fairly fixed. Considerable heterogeneity in microcirculatory vasodilation is evident during physiologic adjustments in flow. For example, as pressure is reduced during autoregulation, dilation is accomplished primarily by arterioles smaller than 100 µm, whereas larger resistance arteries tend to constrict because of the 3 reduction in perfusion pressure (eFig. By contrast, metabolic vasodilation results from a more 4 uniform vasodilation of resistance vessels of all sizes (eFig. Similar inhomogeneity in resistance vessel dilation occurs in response to endothelium-dependent agonists as well as pharmacologic vasodilators. A unique component of subendocardial coronary resistance vessels is the transmural penetrating arteries that course from the epicardium to the subendocardial plexus (see Classic References, Duncker and Bache). These vessels not only are less sensitive to metabolic signals but are also removed from the metabolic stimuli that develop when ischemia is confined to the subendocardium. As a result, local control by altered shear stress and myogenic relaxation to local pressure become critical determinants of diameter in this “upstream” resistance segment. Even during maximal vasodilation, this segment creates an additional longitudinal component of coronary vascular resistance that must be traversed before the arteriolar microcirculation is reached. Because of this greater longitudinal pressure drop, the microcirculatory pressures in subendocardial coronary arterioles are lower than in the subepicardial 4 arterioles. Intraluminal Physical Forces Regulating Coronary Resistance Because much of the coronary resistance vasculature can be upstream from the effects of metabolic mediators of control, local vascular control mechanisms are critically important in orchestrating adequate regional tissue perfusion to the distal microcirculation. The differential expression of mechanisms that is evident among different sizes and classes of coronary resistance vessels coincides with their function. Myogenic Regulation The myogenic response refers to the ability of vascular smooth muscle to oppose changes in coronary 3 arterial diameter. Thus, vessels relax when distending pressure is decreased and constrict when distending pressure is elevated (Fig. Myogenic tone is a property of vascular smooth muscle and occurs across a large size range of coronary resistance arteries in animals as well as in humans. Although the cellular mechanism is uncertain, it depends on vascular smooth muscle calcium entry, perhaps through 2+ stretch-activated L-type Ca channels, eliciting cross-bridge activation. The resistance changes arising from the myogenic response tend to bring local coronary flow back to the original level.

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A suhagra 100mg low price erectile dysfunction treatment by exercise, The short-axis images represent a portion of the anterior buy suhagra 100 mg cheap erectile dysfunction underlying causes, lateral, inferior, and septal walls. B, Vertical long-axis images represent the anterior wall, apex, and inferior wall. Issues related to the patient and the organ being imaged include the stability of the tracer distribution in the organ of interest during the acquisition interval, the absence of motion of the patient or organ of interest or both during the acquisition, and the absence of overlying structures that would attenuate the photon emissions from one region relative to another region across the different projection images. Other quality control issues involve the camera and detector system, including the uniformity of photon detection efficiency across the camera face, as well as the stability of 2 the camera across the entire orbit of acquisition. Discrete motion of the patient, with consequent motion of the heart outside its original field, causes an abnormality in the final images that may be corrected with motion correction software. Imaging artifacts typically occur because of the effects of overlying structures that attenuate photon emissions. These artifacts include breast attenuation in women and attenuation of the inferobasal wall related to the diaphragm, usually seen in men. Strategies to overcome quality-specific problems such as attenuation are described subsequently. Advances in camera and collimator technology have substantially increased the efficiency of count capture, by design features that allow much of the available detector area to image the cardiac field of view, increasing count sensitivity many-fold. One approach uses a series of small, pixilated, solid-state detector columns with cadmium zinc telluride or cesium iodide:thallium crystals, which provide considerably more information for each detected gamma ray. In addition, the design of the solid-state detector with wide-angle tungsten collimators combined with a novel image reconstruction algorithm provides true three-dimensional, 3 patient-specific images localized to the heart. In addition to advances in camera technology, software driving image reconstruction has also evolved. One technique, resolution recovery, improves spatial resolution while reducing noise in the images. Thus, studies acquired over a much shorter time, when reconstructed using these techniques, can yield images 3 with the same signal-to-noise ratio as those using standard techniques and timing. Reduced imaging times should translate to improved patient comfort and satisfaction, as well as less motion and fewer motion artifacts. Because potassium is the major intracellular cation in muscle and is virtually absent in scar 201 tissue, Tl is a well-suited radionuclide for differentiation of normal and ischemic myocardium from 4 scarred myocardium. Thallium-201 emits 80 keV of photon energy and has a physical half-life of 73 hours. The initial myocardial uptake early after intravenous injection of thallium is proportional to regional blood flow. First-pass extraction fraction (the proportion of tracer extracted from the blood as it passes through the myocardium) is high, in the range of 85%. Peak myocardial concentration of thallium is achieved within 5 minutes of injection, with rapid clearance from the intravascular compartment. Although the initial uptake and distribution of thallium are primarily a function of blood flow, the subsequent redistribution of thallium, which begins within 10 to 15 minutes after injection, is unrelated to flow but is related to the rate of its clearance from myocardium, linked to the concentration gradient between myocyte levels and blood levels of thallium (eFig. Thallium clearance is more rapid from normal myocardium with high thallium activity than from myocardium with reduced thallium activity (ischemic myocardium), a process termed differential washout (eFig. A, After initial uptake into the myocyte, an equilibrium is created between the intracellular and extracellular concentrations of thallium. After blood levels diminish during the redistribution phase, the equilibrium favors egress of thallium out of the myocyte. B, On the basis of that equilibrium, thallium concentration diminishes over time in zones of normal uptake while diminishing more slowly in zones with less initial thallium uptake, that is, those with diminished flow reserve or ischemia. In this example, segment 1 of the myocardial schematic is supplied by an artery with an 80% stenosis, and segment 2 is supplied by a normal artery. During peak stress, normal blood flow reserve is present in segment 2; blunted flow reserve, based on the presence of stenosis, is present in segment 1, and there is less initial thallium uptake into segment 1 (time point A). Thallium washout is more rapid from the territory with initially normal uptake and slower from the ischemic zone, creating the phenomenon of “differential washout. Thus a reversible stress defect is seen in segment 1, based on the redistribution properties and differential washout. After stress, the reversal of a thallium defect from the initial peak stress to delayed 3- to 4-hour or 24-hour redistribution images is a marker of reversibly ischemic, viable myocardium. When thallium is injected in the resting state, the extent of thallium defect reversibility from the initial rest images to delayed redistribution images (at 3 to 4 hours) reflects viable myocardium with hypoperfusion at rest. When scarred myocardium is present, the initial rest or stress thallium defect persists over time; such deficits are termed irreversible or fixed defects. The result is that some severely ischemic but viable regions may show no redistribution on either early (3- to 4-hour) or late (24-hour) imaging, even if viable myocardium is present. Viable myocardium in this situation can be revealed by raising blood levels of thallium by reinjection of a small dose (1 to 2 mCi) of thallium at rest. Thus, in some patients, thallium reinjection is necessary to identify viable myocardium when there are irreversible defects on stress-redistribution images. Technetium 99m–Labeled Tracers 99m Technetium 99m ( Tc)–labeled myocardial perfusion tracers were introduced in the clinical arena in the 4 99m 1990s. Despite the excellent 201 myocardial extraction and flow kinetic properties of Tl, its energy spectrum of 80 keV is suboptimal for conventional gamma cameras (ideal photopeak in the 140-keV range). In addition, the long physical half- 201 201 life of Tl (73 hours) limits the amount of Tl that may be administered to stay within acceptable 99m 201 radiation exposure parameters. Sestamibi and tetrofosmin are lipid-soluble cationic compounds with first-pass extraction fraction in the range of 60%. They cross sarcolemmal and mitochondrial membranes of myocytes by passive distribution, driven by the 4 transmembrane electrochemical gradient, and they are retained within the mitochondria. Consequently, myocardial perfusion studies with 99m Tc-labeled tracers require two separate injections, one at peak stress and the second at rest. The interpreter describes the perfusion pattern findings on stress and then visually interprets whether defects observed on the stress images are or are not reversible. Because the imaging data are digital, computer-aided quantitative analysis also may be used. For any type of image interpretation, visual or quantitative, the key elements to be reported include the presence and location of perfusion defects and whether defects on stress images are reversible on the rest images (implying stress-induced ischemia) or whether stress perfusion defects are irreversible or fixed (often implying myocardial infarction) (Fig. Moreover, substantial literature has documented that the extent and the severity of the perfusion abnormality are independently associated with clinical outcomes (risk of adverse events over time) and thus contribute importantly to the information on risk 6 stratification to be conveyed to the ordering clinician. The extent of perfusion abnormality refers to the amount of myocardium or vascular territory that is abnormal, and the severity refers to the magnitude of reduction in tracer uptake in abnormal zone relative to normal. These concepts imply that it is not sufficient to describe a stress perfusion imaging test as simply “abnormal. The final report will incorporate all the clinical data, the stress testing result, and the imaging data to provide comprehensive information to the referring clinician, in a timely and clinically meaningful way. Guidelines for standardized reporting elements are available from professional 7 societies.