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Hecht HS, Shaw L, Chandrashekhar YS, Bax JJ, Narula J. Should NICE guidelines be universally accepted for the evaluation of stable coronary disease? A debate. Eur Heart J 2019; 40:1440-1453. [DOI: 10.1093/eurheartj/ehz024] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 10/09/2018] [Accepted: 01/24/2019] [Indexed: 01/31/2023] Open
Abstract
Abstract
The 2016 National Institute of Health and Care Excellence clinical guideline for the assessment and diagnosis of chest pain positions coronary computed tomography angiography as the first test for all stable chest pain patients without confirmed coronary artery disease and discards the previous emphasis on calculation of pre-test likelihood recommended in their 2012 edition of the guidelines. On the other hand, the American College of Cardiology Foundation/American Heart Association and the European Society of Cardiology guidelines continue to present the stress testing functional modalities as the tests of choice. The aim of this review is to present, in the form of a debate, the pros and cons of these paradigm changing recommendations, with an emphasis on literature review and projection of future needs, with conclusions to be drawn by the reader.
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Affiliation(s)
- Harvey S Hecht
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Saint Luke’s Medical Center, 1111 Amsterdam Ave, New York, NY, USA
| | - Leslee Shaw
- Department of Radiology, Weill Cornell Medicine, 497 East, 61st St., NY, USA
| | - Y S Chandrashekhar
- Division of Cardiology, University of Minnesota School of Medicine, Veterans Affairs Medical Center, 1 Veterans Drive, 111c, Minneapolis, MN, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Jagat Narula
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Saint Luke’s Medical Center, 1111 Amsterdam Ave, New York, NY, USA
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Current Evidence in Cardiothoracic Imaging: Growing Evidence for Coronary Computed Tomography Angiography as a First-line Test in Stable Chest Pain. J Thorac Imaging 2019; 34:4-11. [DOI: 10.1097/rti.0000000000000357] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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53
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Hecht HS. CT derived FFR: "The Game Changer?" revisited. J Cardiovasc Comput Tomogr 2018; 12:447-449. [PMID: 30501874 DOI: 10.1016/j.jcct.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/30/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Harvey S Hecht
- Icahn School of Medicine at Mount Sinai, Mount Sinai Saint Luke's Hospital, 1111 Amsterdam Ave, New York, NY, 10025, USA.
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Nieman K, Shaw LJ, Chandrashekhar Y. Cardiac Computed Tomography 2.0: Adding Physiology to Anatomy. JACC Cardiovasc Imaging 2018; 11:1733-1735. [PMID: 30409333 DOI: 10.1016/j.jcmg.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Koen Nieman
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | | | - Y Chandrashekhar
- Division of Cardiology, University of Minnesota and VA Medical Center, Minneapolis, Minnesota.
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Shah AB, Kirsch J, Bolen MA, Batlle JC, Brown RK, Eberhardt RT, Hurwitz LM, Inacio JR, Jin JO, Krishnamurthy R, Leipsic JA, Rajiah P, Singh SP, White RD, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Chronic Chest Pain-Noncardiac Etiology Unlikely-Low to Intermediate Probability of Coronary Artery Disease. J Am Coll Radiol 2018; 15:S283-S290. [DOI: 10.1016/j.jacr.2018.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022]
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2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36:1953-2041. [PMID: 30234752 DOI: 10.1097/hjh.0000000000001940] [Citation(s) in RCA: 1809] [Impact Index Per Article: 301.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.
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Abstract
Computed tomography (CT) has become an important modality in the evaluation of coronary artery disease (CAD). The tremendous technological advances in CT in the last two decades has made it possible to obtain high quality images of coronary arteries with high spatial and temporal resolutions. Multiple trials have confirmed the accuracy of CT compared to invasive catheter angiography. CT is also able to evaluate beyond the lumen in characterizing and quantifying atherosclerotic plaques, including evaluation of high risk features. Although CTA has low specificity in identification of lesion-specific ischemia, functional techniques are now possible such as CT myocardial perfusion and CT-fractional flow reserve (FFR) which evaluate the hemodynamic significance of stenosis and help with revascularization strategies. Multi-energy CT provides additional information beyond what is possible with a conventional CT and is useful in variety of clinical applications, including myocardial perfusion imaging, lesion characterization and low contrast studies. Large trials have confirmed the ability of CT to predict major adverse cardiovascular events and recent trials have even demonstrated improved clinical outcomes by using CT for the evaluation of CAD. CT is also useful in structural heart disease and 3 D printing is now increasingly used for surgical/interventional planning. Machine learning is evolving rapidly and is likely to impact diagnosis and management.
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Affiliation(s)
- P Rajiah
- From the Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Texas, USA
| | - S Abbara
- From the Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Texas, USA
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Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021-3104. [PMID: 30165516 DOI: 10.1093/eurheartj/ehy339] [Citation(s) in RCA: 5685] [Impact Index Per Article: 947.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Siontis GC, Mavridis D, Greenwood JP, Coles B, Nikolakopoulou A, Jüni P, Salanti G, Windecker S. Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials. BMJ 2018; 360:k504. [PMID: 29467161 PMCID: PMC5820645 DOI: 10.1136/bmj.k504] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, Medline in process, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, SCOPUS, WHO International Clinical Trials Registry Platform, and Clinicaltrials.gov. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Diagnostic randomised controlled trials comparing non-invasive diagnostic modalities in patients presenting with symptoms suggestive of low risk acute coronary syndrome or stable coronary artery disease. DATA SYNTHESIS A random effects network meta-analysis synthesised available evidence from trials evaluating the effect of non-invasive diagnostic modalities on downstream testing and patient oriented outcomes in patients with suspected coronary artery disease. Modalities included exercise electrocardiograms, stress echocardiography, single photon emission computed tomography-myocardial perfusion imaging, real time myocardial contrast echocardiography, coronary computed tomographic angiography, and cardiovascular magnetic resonance. Unpublished outcome data were obtained from 11 trials. RESULTS 18 trials of patients with low risk acute coronary syndrome (n=11 329) and 12 trials of those with suspected stable coronary artery disease (n=22 062) were included. Among patients with low risk acute coronary syndrome, stress echocardiography, cardiovascular magnetic resonance, and exercise electrocardiograms resulted in fewer invasive referrals for coronary angiography than coronary computed tomographic angiography (odds ratio 0.28 (95% confidence interval 0.14 to 0.57), 0.32 (0.15 to 0.71), and 0.53 (0.28 to 1.00), respectively). There was no effect on the subsequent risk of myocardial infarction, but estimates were imprecise. Heterogeneity and inconsistency were low. In patients with suspected stable coronary artery disease, an initial diagnostic strategy of stress echocardiography or single photon emission computed tomography-myocardial perfusion imaging resulted in fewer downstream tests than coronary computed tomographic angiography (0.24 (0.08 to 0.74) and 0.57 (0.37 to 0.87), respectively). However, exercise electrocardiograms yielded the highest downstream testing rate. Estimates for death and myocardial infarction were imprecise without clear discrimination between strategies. CONCLUSIONS For patients with low risk acute coronary syndrome, an initial diagnostic strategy of stress echocardiography or cardiovascular magnetic resonance is associated with fewer referrals for invasive coronary angiography and revascularisation procedures than non-invasive anatomical testing, without apparent impact on the future risk of myocardial infarction. For suspected stable coronary artery disease, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, and differences in the risk of myocardial infarction cannot be ruled out. SYSTEMATIC REVIEW REGISTRATION PROSPERO registry no CRD42016049442.
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Affiliation(s)
- George Cm Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Bernadette Coles
- Cancer Research Wales Library, Velindre National Health Trust, Cardiff, UK
| | | | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, Bern, Switzerland
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60
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Shaw LJ, Blankstein R, Jacobs JE, Leipsic JA, Kwong RY, Taqueti VR, Beanlands RSB, Mieres JH, Flamm SD, Gerber TC, Spertus J, Di Carli MF. Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2017; 10:e000017. [PMID: 29242239 PMCID: PMC5926771 DOI: 10.1161/hci.0000000000000017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.
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61
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Foy AJ, Dhruva SS, Peterson B, Mandrola JM, Morgan DJ, Redberg RF. Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis. JAMA Intern Med 2017; 177:1623-1631. [PMID: 28973101 PMCID: PMC5710269 DOI: 10.1001/jamainternmed.2017.4772] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/03/2017] [Indexed: 12/13/2022]
Abstract
Importance Coronary computed tomography angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing. Objective To compare the clinical effectiveness of CCTA with that of functional stress testing for patients with suspected CAD. Data Sources A systematic literature search was conducted in PubMed and MEDLINE for English-language randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016. Study Selection Researchers selected randomized clinical trials that compared a primary strategy of CCTA with that of functional stress testing for patients with suspected CAD and reported data on patient clinical events and changes in therapy. Data Extraction and Synthesis Two reviewers independently extracted data from and assessed the quality of the trials. This analysis followed the PRISMA statement for reporting systematic reviews and meta-analyses and used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials. The Mantel-Haenszel method was used to conduct the primary analysis. Summary relative risks were calculated with a random-effects model. Main Outcomes and Measures The outcomes of interest were all-cause mortality, cardiac hospitalization, myocardial infarction, invasive coronary angiography, coronary revascularization, new CAD diagnoses, and change in prescription for aspirin and statins. Results Thirteen trials were included, with 10 315 patients in the CCTA arm and 9777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months. There were no statistically significant differences between CCTA and functional stress testing in death (1.0% vs 1.1%; risk ratio [RR], 0.93; 95% CI, 0.71-1.21) or cardiac hospitalization (2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21), but CCTA was associated with a reduction in the incidence of myocardial infarction (0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96). Patients undergoing CCTA were significantly more likely to undergo invasive coronary angiography (11.7% vs 9.1%; RR, 1.33; 95% CI, 1.12-1.59) and revascularization (7.2% vs 4.5%; RR, 1.86; 95% CI, 1.43-2.43). They were also more likely to receive a diagnosis of new CAD and to have initiated aspirin or statin therapy. Conclusions and Relevance Compared with functional stress testing, CCTA is associated with a reduced incidence of myocardial infarction but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. Despite these differences, CCTA is not associated with a reduction in mortality or cardiac hospitalizations.
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Affiliation(s)
- Andrew J. Foy
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Sanket S. Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brandon Peterson
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - John M. Mandrola
- Louisville Cardiology Group, Baptist Health, Louisville, Kentucky
| | - Daniel J. Morgan
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Rita F. Redberg
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Editor, JAMA Internal Medicine
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62
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Williams MC, Shambrook J, Nicol ED. Assessment of patients with stable chest pain. Heart 2017; 104:691-699. [PMID: 29084808 DOI: 10.1136/heartjnl-2017-311212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/11/2017] [Accepted: 09/17/2017] [Indexed: 11/03/2022] Open
Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - James Shambrook
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Edward D Nicol
- Departments of Cardiology and Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Faculty of Health Sciences, National Heart and Lung Institute, Imperial College London, London, UK
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Comparative Effectiveness Trials of Imaging-Guided Strategies in Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2017; 10:321-334. [PMID: 28279380 DOI: 10.1016/j.jcmg.2016.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/21/2022]
Abstract
The evaluation of patients with suspected stable ischemic heart disease is among the most common diagnostic evaluations with nearly 20 million imaging and exercise stress tests performed annually in the United States. Over the past decade, there has been an evolution in imaging research with an ever-increasing focus on larger registries and randomized trials comparing the effectiveness of varying diagnostic algorithms. The current review highlights recent randomized trial evidence with a particular focus comparing the effectiveness of cardiac imaging procedures within the stable ischemic heart disease evaluation for coronary artery disease detection, angina, and other quality of life measures, and major clinical outcomes. Also highlighted are secondary analyses from these trials on the economic findings related to comparative cost differences across diagnostic testing strategies.
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65
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Edvardsen T, Donal E, Bucciarelli-Ducci C, Maurovich-Horvat P, Maurer G, Popescu BA. The years 2015-2016 in the European Heart Journal-Cardiovascular Imaging. Part I. Eur Heart J Cardiovasc Imaging 2017; 18:1092-1098. [PMID: 28984893 DOI: 10.1093/ehjci/jex192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/08/2017] [Indexed: 11/12/2022] Open
Abstract
The multimodality cardiovascular imaging journal, European Heart Journal-Cardiovascular Imaging, was launched in 2012. It has gained an impressive impact factor of 5.99 during its 5 first years and is now established as the most important cardiovascular imaging journal in Europe. The most important studies from the journal's forth and fifth years will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.
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Affiliation(s)
- Thor Edvardsen
- Department of Cardiology, Centre of Cardiological Innovation Oslo University Hospital, Rikshospitalet and University of Oslo, PO Box 4950 Nydalen, NO-0424 Oslo, Norway
| | - Erwan Donal
- Cardiologie Department and CIC-IT 1414, CHU Rennes, Hôpital Pontchaillou, LTSI INSERM U 1099, University Rennes-1, 35000 Rennes, France
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, University Hospitals Bristol NHS Trust, Upper Maudlin St, Bristol, BS2 8HW, UK and Clinical Research and Imaging Centre (CRIC) Bristol, 60 St Michael Hill, Bristol, BS2 8DX, UK
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group (CIRG), Heart and Vascular Center, Semmelweis University, 68 Varosmajor u., 1122 Budapest, Hungary
| | - Gerald Maurer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Wien, Austria
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila'-Euroecolab, Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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Rajiah P, Maroules CD. Myocardial ischemia testing with computed tomography: emerging strategies. Cardiovasc Diagn Ther 2017; 7:475-488. [PMID: 29255691 DOI: 10.21037/cdt.2017.09.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although cardiac computed tomography (CT) has high negative predictive value to exclude obstructive coronary artery disease (CAD), particularly in the low to intermediate risk population, it has low specificity in the diagnosis of ischemia-inducing lesions. This inability to predict hemodynamically significant stenosis hampers the ability of CT to be an effective gatekeeper for invasive angiography and to guide appropriate revascularization. Recent advances in CT technology have resulted in the development of multiple techniques to provide hemodynamic information and detect lesion-specific ischemia, namely CT perfusion (CTP), CT-derived fractional flow reserve (CT-FFR) and coronary transluminal attenuation gradient (TAG). In this article, we provide a perspective on these emerging CT techniques in the evaluation of myocardial ischemia.
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Affiliation(s)
- Prabhakar Rajiah
- Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Texas, USA
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67
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Udelson JE, Hoffmann U. The United Kingdom's National Institute for Health and Care Excellence guideline on chest pain of recent onset: A United States perspective. J Nucl Cardiol 2017; 24:1535-1539. [PMID: 28798998 DOI: 10.1007/s12350-017-1025-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/24/2017] [Indexed: 01/14/2023]
Affiliation(s)
- James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Box 70, 800 Washington St, Boston, MA, 02111, USA.
| | - Udo Hoffmann
- Cardiac MR PET CT Program and Department of Radiology, Massachusetts General Hospital and Harvard Medical School Boston, Boston, MA, USA
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68
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Hwang IC, Choi SJ, Choi JE, Ko EB, Suh JK, Choi I, Kang HJ, Kim YJ, Kim JY. Comparison of mid- to long-term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta-analysis of randomized trials. Clin Cardiol 2017; 40:1129-1138. [PMID: 28914973 DOI: 10.1002/clc.22799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/07/2017] [Accepted: 08/14/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD). HYPOTHESIS CCTA as initial diagnostic strategy results in better mid- to long-term outcomes than usual care in patients with suspected CAD. METHODS We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow-up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all-cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies. RESULTS Twelve trials were included (20 014 patients; mean follow-up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52-0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all-cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12-2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11-2.00, P = 0.007). CONCLUSIONS Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.
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Affiliation(s)
- In-Chang Hwang
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sol Ji Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Ji Eun Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Eun-Bi Ko
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea.,Department of Health Administration, Yonsei University Graduate School, Wonju, Republic of Korea
| | - Jae Kyung Suh
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Insun Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Hyun-Jae Kang
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong-Jin Kim
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joo Youn Kim
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
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Healthcare Policy Statement on the Utility of Coronary Computed Tomography for Evaluation of Cardiovascular Conditions and Preventive Healthcare: From the Health Policy Working Group of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:404-414. [DOI: 10.1016/j.jcct.2017.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/14/2017] [Accepted: 08/14/2017] [Indexed: 12/14/2022]
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Bittencourt MS, Blankstein R. Coronary computed tomography angiography: How should we act on what we find? J Nucl Cardiol 2017; 24:1279-1281. [PMID: 27072002 DOI: 10.1007/s12350-016-0494-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 03/29/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Márcio Sommer Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP), University of São Paulo, São Paulo, Brazil
- Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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71
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Beller GA. How Should We Interpret the Decrease in Annual Volume of Stress Imaging Tests for Evaluation of Suspected or Known Coronary Artery Disease With Fewer High-Risk Test Results? Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006702. [PMID: 28687540 DOI: 10.1161/circimaging.117.006702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- George A Beller
- From the Cardiovascular Division, University of Virginia Health System, Charlottesville.
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72
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Adamson PD, Newby DE. The true value of The National Institute for Health and Care Excellence guidance. BRITISH HEART JOURNAL 2017; 103:1056. [DOI: 10.1136/heartjnl-2017-311859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Williams MC, Hunter A, Shah A, Assi V, Lewis S, Mangion K, Berry C, Boon NA, Clark E, Flather M, Forbes J, McLean S, Roditi G, van Beek EJ, Timmis AD, Newby DE. Symptoms and quality of life in patients with suspected angina undergoing CT coronary angiography: a randomised controlled trial. Heart 2017; 103:995-1001. [PMID: 28246175 PMCID: PMC5529983 DOI: 10.1136/heartjnl-2016-310129] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/01/2016] [Accepted: 08/15/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In patients with suspected angina pectoris, CT coronary angiography (CTCA) clarifies the diagnosis, directs appropriate investigations and therapies, and reduces clinical events. The effect on patient symptoms is currently unknown. METHODS In a prospective open-label parallel group multicentre randomised controlled trial, 4146 patients with suspected angina due to coronary heart disease were randomised 1:1 to receive standard care or standard care plus CTCA. Symptoms and quality of life were assessed over 6 months using the Seattle Angina Questionnaire and Short Form 12. RESULTS Baseline scores indicated mild physical limitation (74±0.4), moderate angina stability (44±0.4), modest angina frequency (68±0.4), excellent treatment satisfaction (92±0.2) and moderate impairment of quality of life (55±0.3). Compared with standard care alone, CTCA was associated with less marked improvements in physical limitation (difference -1.74 (95% CIs, -3.34 to -0.14), p=0.0329), angina frequency (difference -1.55 (-2.85 to -0.25), p=0.0198) and quality of life (difference -3.48 (-4.95 to -2.01), p<0.0001) at 6 months. For patients undergoing CTCA, improvements in symptoms were greatest in those diagnosed with normal coronary arteries or who had their preventative therapy discontinued, and least in those with moderate non-obstructive disease or had a new prescription of preventative therapy (p<0.001 for all). CONCLUSIONS While improving diagnosis, treatment and outcome, CTCA is associated with a small attenuation of the improvements in symptoms and quality of life due to the detection of moderate non-obstructive coronary artery disease. TRIAL REGISTRATION NUMBER NCT01149590.
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Affiliation(s)
- Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Amanda Hunter
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Anoop Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Valentina Assi
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Stephanie Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Mangion
- Institute for Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Colin Berry
- Institute for Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nicholas A Boon
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Clark
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | | | | | - Giles Roditi
- Institute for Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edwin Jr van Beek
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Adam D Timmis
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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La Grutta L, Toia P, Maffei E, Cademartiri F, Lagalla R, Midiri M. Infarct characterization using CT. Cardiovasc Diagn Ther 2017; 7:171-188. [PMID: 28540212 DOI: 10.21037/cdt.2017.03.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Myocardial infarction (MI) is a major cause of death and disability worldwide. The incidence is not expected to diminish, despite better prevention, diagnosis and treatment, because of the ageing population in industrialized countries and unhealthy lifestyles in developing countries. Nowadays it is highly requested an imaging tool able to evaluate MI and viability. Technology improvements determined an expansion of clinical indications from coronary plaque evaluation to functional applications (perfusion, ischemia and viability after MI) integrating additional phases and information in the mainstream examination. Cardiac computed tomography (CCT) and cardiac MR (CMR) employ different contrast media, but may characterize MI with overlapping imaging findings due to the similar kinetics and tissue distribution of gadolinium and iodinated contrast media. CCT may detect first-pass perfusion defects, dynamic perfusion after pharmacological stress, and delayed enhancement (DE) of non-viable territories.
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Affiliation(s)
| | - Patrizia Toia
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
| | - Erica Maffei
- Department of Radiology, Montreal Heart Institute/Universitè de Montreal, Montreal, Canada
| | - Filippo Cademartiri
- Department of Radiology, Montreal Heart Institute/Universitè de Montreal, Montreal, Canada.,Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Roberto Lagalla
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
| | - Massimo Midiri
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
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75
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Van Mieghem CAG. CT as gatekeeper of invasive coronary angiography in patients with suspected CAD. Cardiovasc Diagn Ther 2017; 7:189-195. [PMID: 28540213 PMCID: PMC5422839 DOI: 10.21037/cdt.2017.04.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/29/2017] [Indexed: 01/07/2023]
Abstract
Cardiac CT has been accepted as a valuable diagnostic tool in today's patient care. However, several other noninvasive, in particular, functional diagnostic tests are available on the menu for the ordering clinician and target more or less the same patient population. These tests come with a cost and financial constraints in the present economic environment will no longer allow its indiscriminate use. The gatekeeper function of a diagnostic testing strategy implies that a test is selected judiciously with the aim of preventing access to invasive yet expensive coronary angiography. On the basis of current knowledge, cardiac CT stands a good chance to claim the position of effective gatekeeper to the cathlab.
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76
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Karthikeyan G, Guzic Salobir B, Jug B, Devasenapathy N, Alexanderson E, Vitola J, Kraft O, Ozkan E, Sharma S, Purohit G, Dolenc Novak M, Meave A, Trevethan S, Cerci R, Zier S, Gotthardtová L, Jonszta T, Altin T, Soydal C, Patel C, Gulati G, Paez D, Dondi M, Kashyap R. Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study). J Nucl Cardiol 2017; 24:507-517. [PMID: 27796852 PMCID: PMC5413523 DOI: 10.1007/s12350-016-0664-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/14/2016] [Accepted: 08/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA). METHODS In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months. RESULTS We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months. CONCLUSION In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA. TRIAL REGISTRATION clinicaltrials.gov identification number NCT01368770.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Barbara Guzic Salobir
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Jug
- Department of Vascular Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Erick Alexanderson
- Department of Nuclear Medicine, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico
| | - Joao Vitola
- Quanta Diagnóstico & Terapia, Curitiba, Brazil
| | - Otakar Kraft
- Department of Nuclear Medicine, Faculty Hospital Ostrava, Ostrava, Czech Republic
| | - Elgin Ozkan
- Department of Nuclear Medicine, Ankara University Medical Faculty, Ankara, Turkey
| | - Saket Sharma
- Indian Institute of Public Health-Delhi, Gurgaon, India
| | - Gaurav Purohit
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Maja Dolenc Novak
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aloha Meave
- Department of Radiology, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico
| | - Sergio Trevethan
- Department of Nuclear Medicine, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico
| | | | - Sandra Zier
- Quanta Diagnóstico & Terapia, Curitiba, Brazil
| | - Lucia Gotthardtová
- Department of Cardiology, Faculty Hospital Ostrava, Ostrava, Czech Republic
| | - Tomáš Jonszta
- Department of Radiology, Faculty Hospital Ostrava, Ostrava, Czech Republic
| | - Timucin Altin
- Department of Cardiology, Ankara University Medical Faculty, Ankara, Turkey
| | - Cigdem Soydal
- Department of Nuclear Medicine, Ankara University Medical Faculty, Ankara, Turkey
| | - Chetan Patel
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gurpreet Gulati
- Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Diana Paez
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Maurizio Dondi
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Ravi Kashyap
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
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Williams MC, Moss A, Nicol E, Newby DE. Cardiac CT Improves Outcomes in Stable Coronary Heart Disease: Results of Recent Clinical Trials. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017; 10:14. [PMID: 28446942 PMCID: PMC5385198 DOI: 10.1007/s12410-017-9411-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this study was to review the recent randomised controlled trials of coronary computed tomography angiography (CCTA) for patients with stable coronary artery disease. RECENT FINDINGS The initial results and subsequent papers from the SCOT-HEART (Scottish COmputed Tomography of the HEART) and PROMISE (PROspective Multicentre Imaging Study for Evaluation of chest pain) trials have shown that CCTA is a safe and appropriate addition to standard care or alternative to functional testing. The SCOT-HEART study showed that CCTA changes diagnoses, improves diagnostic certainty, changes management, leads to more appropriate use of invasive coronary angiography, and reduces fatal and non-fatal myocardial infarction. A meta-analysis of the four randomised controlled trials showed that CCTA leads to a major reduction in myocardial infarction in patients with stable chest pain. SUMMARY CCTA is now an established technique for the assessment of coronary artery disease. Recent 'test and treat' randomised controlled trials have shown that CCTA guided changes in management can improve clinical outcomes.
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Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB UK
| | - Alastair Moss
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB UK
| | - Edward Nicol
- Royal Brompton and Harefield NHS Trust Departments of Cardiology and Radiology, London, UK
| | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB UK
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Gray AJ, Roobottom C, Smith JE, Goodacre S, Oatey K, O’Brien R, Storey RF, Na L, Lewis SC, Thokala P, Newby DE. The RAPID-CTCA trial (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) - a multicentre parallel-group randomised trial to compare early computerised tomography coronary angiography versus standard care in patients presenting with suspected or confirmed acute coronary syndrome: study protocol for a randomised controlled trial. Trials 2016; 17:579. [PMID: 27923390 PMCID: PMC5142154 DOI: 10.1186/s13063-016-1717-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/19/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Emergency department attendances with chest pain requiring assessment for acute coronary syndrome (ACS) are a major global health issue. Standard assessment includes history, examination, electrocardiogram (ECG) and serial troponin testing. Computerised tomography coronary angiography (CTCA) enables additional anatomical assessment of patients for coronary artery disease (CAD) but has only been studied in very low-risk patients. This trial aims to investigate the effect of early CTCA upon interventions, event rates and health care costs in patients with suspected/confirmed ACS who are at intermediate risk. METHODS/DESIGN Participants will be recruited in about 35 tertiary and district general hospitals in the UK. Patients ≥18 years old with symptoms with suspected/confirmed ACS with at least one of the following will be included: (1) ECG abnormalities, e.g. ST-segment depression >0.5 mm; (2) history of ischaemic heart disease; (3) troponin elevation above the 99th centile of the normal reference range or increase in high-sensitivity troponin meeting European Society of Cardiology criteria for 'rule-in' of myocardial infarction (MI). The early use of ≥64-slice CTCA as part of routine assessment will be compared to standard care. The primary endpoint will be 1-year all-cause death or recurrent type 1 or type 4b MI at 1 year, measured as the time to such event. A number of secondary clinical, process and safety endpoints will be collected and analysed. Cost effectiveness will be estimated in terms of the lifetime incremental cost per quality-adjusted life year gained. We plan to recruit 2424 (2500 with ~3% drop-out) evaluable patients (1212 per arm) to have 90% power to detect a 20% versus 15% difference in 1-year death or recurrent type 1 MI or type 4b MI, two-sided p < 0.05. Analysis will be on an intention-to-treat basis. The relationship between intervention and the primary outcome will be analysed using Cox proportional hazard regression adjusted for study site (used to stratify the randomisation), age, baseline Global Registry of Acute Coronary Events score, previous CAD and baseline troponin level. The results will be expressed as a hazard ratio with the corresponding 95% confidence intervals and p value. DISCUSSION The Rapid Assessment of Potential Ischaemic Heart Disease with CTCA (RAPID-CTCA) trial will recruit 2500 participants across about 35 hospital sites. It will be the first study to investigate the role of CTCA in the early assessment of patients with suspected or confirmed ACS who are at intermediate risk and including patients who have raised troponin measurements during initial assessment. TRIAL REGISTRATION ISRCTN19102565 . Registered on 3 October 2014. ClinicalTrials.gov: NCT02284191.
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Affiliation(s)
- Alasdair J. Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, British Heart Foundation, Centre for Cardiovascular Science, Edinburgh, UK
| | - Carl Roobottom
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Jason E. Smith
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel O’Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Lumine Na
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Steff C. Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David E. Newby
- University of Edinburgh, British Heart Foundation, Centre for Cardiovascular Science, Edinburgh, UK
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Muhlestein JB, Moreno FL. Coronary Computed Tomography Angiography for Screening in Patients with Diabetes: Can Enhanced Detection of Subclinical Coronary Atherosclerosis Improve Outcome? Curr Atheroscler Rep 2016; 18:64. [DOI: 10.1007/s11883-016-0620-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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80
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Bittencourt MS, Hulten EA, Murthy VL, Cheezum M, Rochitte CE, Di Carli MF, Blankstein R. Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care: A Meta-Analysis. Circ Cardiovasc Imaging 2016; 9:e004419. [PMID: 27072303 DOI: 10.1161/circimaging.115.004419] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/18/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Limited data exist on how noninvasive testing options compare for evaluating patients with suspected stable coronary artery disease. In this study, we have performed a meta-analysis of randomized controlled trials comparing the use of coronary computed tomographic angiography (CTA) with usual care. METHODS AND RESULTS We systematically searched databases for randomized clinical trials comparing coronary CTA with usual care for the evaluation of stable chest pain with follow-up for cardiovascular outcomes. The primary outcomes were myocardial infarction and all-cause mortality. We identified 4 randomized clinical trials, including a total of 7403 patients undergoing coronary CTA and 7414 patients undergoing usual care with various functional testing approaches. When compared with usual care, the use of coronary CTA was associated with a significant reduction in the annual rate of myocardial infarction (rate ratio, 0.69; 95% confidence interval, 0.49-0.98; P=0.038), but no difference was found in all-cause mortality. There was a trend toward more invasive coronary angiographies among patients undergoing coronary CTA (odds ratio, 1.33; 95% confidence interval, 0.95-1.84; P=0.09) and higher use of coronary revascularizations (odds ratio, 1.77; 95% confidence interval, 1.14-2.75). Significant heterogeneity for invasive coronary angiography and revascularization was noted, which was attributable to the Scottish Computed Tomography of the HEART (SCOT-HEART) study. We found no difference in the rate of admission for cardiac chest pain (rate ratio, 1.21; 95% confidence interval, 0.95-1.54). CONCLUSIONS In comparison to usual care, an initial investigation of suspected stable coronary artery disease using coronary CTA resulted in a significant reduction in myocardial infarction, an increased incidence of coronary revascularization, and no effect in all-cause mortality. Future studies should further define whether the potential reduction in myocardial infarction identified justifies the increased resource utilization associated with coronary CTA.
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Affiliation(s)
- Márcio Sommer Bittencourt
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
| | - Edward A Hulten
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.)
| | - Venkatesh L Murthy
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.)
| | - Michael Cheezum
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.)
| | - Carlos E Rochitte
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.)
| | - Marcelo F Di Carli
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.)
| | - Ron Blankstein
- From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.)
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81
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Hecht HS, Narula J, Fearon WF. Fractional Flow Reserve and Coronary Computed Tomographic Angiography. Circ Res 2016; 119:300-16. [DOI: 10.1161/circresaha.116.307914] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/25/2016] [Indexed: 12/14/2022]
Abstract
Invasive fractional flow reserve (FFR) is now the gold standard for intervention. Noninvasive functional imaging analyses derived from coronary computed tomographic angiography (CTA) offer alternatives for evaluating lesion-specific ischemia. CT-FFR, CT myocardial perfusion imaging, and transluminal attenuation gradient/corrected contrast opacification have been studied using invasive FFR as the gold standard. CT-FFR has demonstrated significant improvement in specificity and positive predictive value compared with CTA alone for predicting FFR of ≤0.80, as well as decreasing the frequency of nonobstructive invasive coronary angiography. High-risk plaque characteristics have also been strongly implicated in abnormal FFR. Myocardial computed tomographic perfusion is an alternative method with promising results; it involves more radiation and contrast. Transluminal attenuation gradient/corrected contrast opacification is more controversial and may be more related to vessel diameter than stenosis. Important considerations remain: (1) improvement of CTA quality to decrease unevaluable studies, (2) is the diagnostic accuracy of CT-FFR sufficient? (3) can CT-FFR guide intervention without invasive FFR confirmation? (4) what are the long-term outcomes of CT-FFR–guided treatment and how do they compare with other functional imaging-guided paradigms? (5) what degree of stenosis on CTA warrants CT-FFR? (6) how should high-risk plaque be incorporated into treatment decisions? (7) how will CT-FFR influence other functional imaging test utilization, and what will be the effect on the practice of cardiology? (8) will a workstation-based CT-FFR be mandatory? Rapid progress to date suggests that CTA-based lesion-specific ischemia will be the gatekeeper to the cardiac catheterization laboratory and will transform the world of intervention.
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Affiliation(s)
- Harvey S. Hecht
- From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.)
| | - Jagat Narula
- From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.)
| | - William F. Fearon
- From the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York (H.S.H., J.N.); Department of Cardiology, Stanford University School of Medicine, CA (W.F.F.)
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82
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Fordyce CB, Newby DE, Douglas PS. Diagnostic Strategies for the Evaluation of Chest Pain: Clinical Implications From SCOT-HEART and PROMISE. J Am Coll Cardiol 2016; 67:843-52. [PMID: 26892420 DOI: 10.1016/j.jacc.2015.11.055] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/02/2015] [Accepted: 11/12/2015] [Indexed: 11/17/2022]
Abstract
SCOT-HEART (Scottish COmputed Tomography of the HEART) and PROMISE (PROspective Multicenter Imaging Study for Evaluation of chest pain) represent the 2 largest and most comprehensive cardiovascular imaging outcome trials in patients with stable chest pain and provide significant insights into patient diagnosis, management, and outcomes. These trials are particularly timely, given the well-recognized knowledge gaps and widespread use of noninvasive imaging. The overall goal of this review is to distill the data generated from these 2 pivotal trials to better inform the practicing clinician in the selection of noninvasive testing for stable chest pain. Similarities and differences between SCOT-HEART and PROMISE are highlighted, and clinical and practical implications are discussed. Both trials show that coronary computed tomography angiography should have a greater role in the diagnostic pathway of patients with stable chest pain.
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Affiliation(s)
| | - David E Newby
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, Edinburgh, United Kingdom
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83
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Mark DB, Anstrom KJ, Sheng S, Baloch KN, Daniels MR, Hoffmann U, Patel MR, Cooper LS, Lee KL, Douglas PS. Quality-of-Life Outcomes With Anatomic Versus Functional Diagnostic Testing Strategies in Symptomatic Patients With Suspected Coronary Artery Disease: Results From the PROMISE Randomized Trial. Circulation 2016; 133:1995-2007. [PMID: 27143676 PMCID: PMC4879021 DOI: 10.1161/circulationaha.115.020259] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial found that initial use of ≥64 detector-row computed tomography angiography versus standard functional testing strategies (exercise ECG, stress nuclear methods, or stress echocardiography) did not improve clinical outcomes in 10 003 stable symptomatic patients with suspected coronary artery disease requiring noninvasive testing. Symptom burden and quality of life (QOL) were major secondary outcomes. METHODS AND RESULTS We prospectively collected a battery of QOL instruments in 5985 patients at baseline and 6, 12, and 24 months postrandomization. The prespecified primary QOL measures were the Duke Activity Status Index and the Seattle Angina Questionnaire frequency and QOL scales. All comparisons were made as randomized. Baseline variables were well balanced in the 2982 patients randomly assigned to computed tomography angiography testing and the 3003 patients randomly assigned to functional testing. The Duke Activity Status Index improved substantially in both groups over the first 6 months following testing, but we found no evidence for a strategy-related difference (mean difference [anatomic - functional] at 24 months of follow-up, 0.1 [95% confidence interval, -0.9 to 1.1]). Similar results were seen for the Seattle Angina Questionnaire frequency scale (mean difference at 24 months, -0.2; 95% confidence interval, -0.8 to 0.4) and QOL scale (mean difference at 24 months, -0.2; 95% confidence interval, -1.3 to 0.9). None of the secondary QOL measures showed a consistent strategy-related difference. CONCLUSIONS In symptomatic patients with suspected coronary artery disease who required noninvasive testing, symptoms and QOL improved significantly. However, a strategy of initial anatomic testing, in comparison with functional testing, did not provide an incremental benefit for QOL over 2 years of follow-up. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01174550.
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Affiliation(s)
- Daniel B Mark
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.).
| | - Kevin J Anstrom
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Shubin Sheng
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Khaula N Baloch
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Melanie R Daniels
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Udo Hoffmann
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Manesh R Patel
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Lawton S Cooper
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Kerry L Lee
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Pamela S Douglas
- From Outcomes Research Group (D.B.M., K.J.A., S.S., K.N.B., M.R.D.), Duke Clinical Research Institute (D.B.M., K.J.A., S.S., K.N.B., M.R.D., M.R.P., K.L.L., P.S.D.), Duke University Medical Center, Durham, NC; Massachusetts General Hospital, Harvard Medical School, Boston (U.H.); and National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
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84
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Nieman K. Clinical Value of Coronary Computed Tomographic Angiography in Patients With Stable Angina. Circ Cardiovasc Imaging 2016; 9:e004783. [DOI: 10.1161/circimaging.116.004783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Koen Nieman
- From the Departments of Cardiology and Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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85
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López-Fernández T, Saura D, Rodríguez-Palomares JF, Aguadé-Bruix S, Pérez de Isla L, Barba-Cosials J. Selección de temas de actualidad en imagen cardiaca 2015. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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86
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Fordyce CB, Douglas PS. Optimal non-invasive imaging test selection for the diagnosis of ischaemic heart disease. Heart 2016; 102:555-64. [DOI: 10.1136/heartjnl-2015-307764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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87
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Agus AM, McKavanagh P, Lusk L, Verghis RM, Walls GM, Ball PA, Trinick TR, Harbinson MT, Donnelly PM. The cost-effectiveness of cardiac computed tomography for patients with stable chest pain. Heart 2016; 102:356-62. [DOI: 10.1136/heartjnl-2015-308247] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 11/30/2015] [Indexed: 11/04/2022] Open
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88
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López-Fernández T, Saura D, Rodríguez-Palomares JF, Aguadé-Bruix S, Pérez de Isla L, Barba-Cosials J. Cardiac Imaging 2015: A Selection of Topical Issues. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2016; 69:286-93. [PMID: 26752219 DOI: 10.1016/j.rec.2015.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 10/03/2015] [Indexed: 01/22/2023]
Affiliation(s)
| | - Daniel Saura
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - José F Rodríguez-Palomares
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Institut de Recerca-VHIR, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | - Joaquín Barba-Cosials
- Departamento de Cardiología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
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89
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Farkouh ME, Douglas PS. The Management of Acute Chest Pain. J Am Coll Cardiol 2016; 67:27-8. [DOI: 10.1016/j.jacc.2015.09.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/15/2015] [Indexed: 11/24/2022]
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90
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McEneny J, McKavanagh P, York E, Nadeem N, Harbinson M, Stevenson M, Ball P, Lusk L, Trinick T, Young IS, McKay GJ, Donnelly PM. Serum- and HDL3-serum amyloid A and HDL3-LCAT activity are influenced by increased CVD-burden. Atherosclerosis 2015; 244:172-8. [PMID: 26647373 DOI: 10.1016/j.atherosclerosis.2015.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/06/2015] [Accepted: 11/18/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND High density lipoproteins (HDL) protect against cardiovascular disease (CVD). However, increased serum amyloid-A (SAA) related inflammation may negate this property. This study investigated if SAA was related to CVD-burden. METHODS Subjects referred to the rapid chest pain clinic (n = 240) had atherosclerotic burden assessed by cardiac computerised tomography angiography. Subjects were classified as: no-CVD (n = 106), non-obstructive-CVD, stenosis<50% (n = 58) or moderate/significant-CVD, stenosis ≥50% (n = 76). HDL was subfractionated into HDL2 and HDL3 by rapid-ultracentrifugation. SAA-concentration was measured by ELISA and lecithin cholesterol acyltransferase (LCAT) activity measured by a fluorimetric assay. RESULTS We illustrated that serum-SAA and HDL3-SAA-concentration were higher and HDL3-LCAT-activity lower in the moderate/significant-CVD-group, compared to the no-CVD and non-obstructive-CVD-groups (percent differences: serum-SAA, +33% & +30%: HDL3-SAA, +65% and +39%: HDL3-LCAT, -6% & -3%; p < 0.05 for all comparisons). We also identified a positive correlation between serum-SAA and HDL3-SAA (r = 0.698; p < 0.001) and a negative correlation between HDL3-SAA and HDL3-LCAT-activity (r = -0.295; p = 0.003), while CVD-burden positively correlated with serum-SAA (r = 0.150; p < 0.05) and HDL3-SAA (r = 0.252; p < 0.001) and negatively correlated with HDL3-LCAT-activity (r = -0.182; p = 0.006). Additionally, multivariate regression analysis adjusted for age, gender, CRP and serum-SAA illustrated that HDL3-SAA was significantly associated with modifying CVD-risk of moderate/significant CVD-risk (p < 0.05). CONCLUSION This study has demonstrated increased SAA-related inflammation in subjects with moderate/significant CVD-burden, which appeared to impact on the antiatherogenic potential of HDL. We suggest that SAA may be a useful biomarker to illustrate increased CVD-burden, although this requires further investigation.
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Affiliation(s)
- Jane McEneny
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom.
| | - Peter McKavanagh
- Cardiovascular Research Department, Ulster Hospital, Belfast, United Kingdom
| | - Edmund York
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Nida Nadeem
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Mark Harbinson
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Michael Stevenson
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Peter Ball
- Cardiovascular Research Department, Ulster Hospital, Belfast, United Kingdom
| | - Lisa Lusk
- Cardiovascular Research Department, Ulster Hospital, Belfast, United Kingdom
| | - Thomas Trinick
- Clinical Biochemistry, Ulster Hospital, Belfast, United Kingdom
| | - Ian S Young
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Gareth J McKay
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Patrick M Donnelly
- Cardiovascular Research Department, Ulster Hospital, Belfast, United Kingdom
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91
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McKavanagh P, Walls G, McCune C, Malloy J, Harbinson MT, Ball PA, Donnelly PM. The Essentials of Cardiac Computerized Tomography. Cardiol Ther 2015; 4:117-29. [PMID: 26536882 PMCID: PMC4675750 DOI: 10.1007/s40119-015-0052-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Indexed: 10/25/2022] Open
Abstract
Cardiac computerized tomography (CT) has evolved from a research tool to an important diagnostic investigation in cardiology, and is now recommended in European, US, and UK guidelines. This review is designed to give the reader an overview of the current state of cardiac CT. The role of cardiac CT is multifaceted, and includes risk stratification, disease detection, coronary plaque quantification, defining congenital heart disease, planning for structural intervention, and, more recently, assessment of ischemia. This paper addresses basic principles as well as newer evidence.
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