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Identifying patients with acute total coronary occlusion in NSTEACS: finding the high-risk needle in the haystack. Eur Heart J 2017; 38:3090-3093. [DOI: 10.1093/eurheartj/ehx520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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202
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Uretsky S, Argulian E, Supariwala A, Agarwal SK, El-Hayek G, Chavez P, Awan H, Jagarlamudi A, Puppala SP, Cohen R, Rozanski A. Comparative effectiveness of coronary CT angiography vs stress cardiac imaging in patients following hospital admission for chest pain work-up: The Prospective First Evaluation in Chest Pain (PERFECT) Trial. J Nucl Cardiol 2017; 24:1267-1278. [PMID: 27048306 DOI: 10.1007/s12350-015-0354-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Because the frequency of cardiac event rates is low among chest pain patients following either performance of coronary CT angiography (CCTA) or stress testing, there is a need to better assess how these tests influence the central management decisions that follow from cardiac testing. The present study was performed to assess the relative impact of CCTA vs stress testing on medical therapies and downstream resource utilization among patients admitted for the work-up of chest pain. METHODS The admitted patients were randomized in a 1:1 ratio to either cardiac imaging stress test or CCTA. Primary outcomes were time to discharge, change in medication usage, and frequency of downstream testing, cardiac interventions, and cardiovascular re-hospitalizations. We randomized 411 patients, 205 to stress testing, and 206 to CCTA. RESULTS There were no differences in time to discharge or initiation of new cardiac medications at discharge. At 1 year follow-up, there was no difference in the number of patients who underwent cardiovascular downstream tests in the CCTA vs stress test patients (21% vs 15%, P = .1) or cardiovascular hospitalizations (14% vs 16%, P = .5). However, there was a higher frequency of invasive angiography in the CCTA group (11% vs 2%, P = .001) and percutaneous coronary interventions (6% vs 0%, P < .001). CONCLUSIONS Randomization of hospitalized patients admitted for chest pain work-up to either CCTA or to stress testing resulted in similar discharge times, change in medical therapies at discharge, frequency of downstream noninvasive testing, and repeat hospitalizations. However, a higher frequency of invasive coronary angiography and revascularization procedures were performed in the CCTA arm. (ClinicalTrials.gov number, NCT01604655.).
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Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Morristown Medical Center, Gagnon Cardiovascular Institute, 100 Madison Ave, Morristown, NJ, 07960, USA.
| | - Edgar Argulian
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Azhar Supariwala
- Northshore LIJ Southside Hospital, Hofstra School of Medicine, NSLIJHS, Bayshore, NY, USA
| | - Shiv K Agarwal
- Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Georges El-Hayek
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Patricia Chavez
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Hira Awan
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Ashadevi Jagarlamudi
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Siva P Puppala
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Randy Cohen
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Alan Rozanski
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
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Durand E, Bauer F, Mansencal N, Azarine A, Diebold B, Hagege A, Perdrix L, Gilard M, Jobic Y, Eltchaninoff H, Bensalah M, Dubourg B, Caudron J, Niarra R, Chatellier G, Dacher JN, Mousseaux E. Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study. Int J Cardiol 2017; 241:463-469. [DOI: 10.1016/j.ijcard.2017.02.129] [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: 09/30/2016] [Revised: 12/10/2016] [Accepted: 02/24/2017] [Indexed: 11/15/2022]
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204
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Woodard PK, McWilliams SR, Raptis DA, Hollander JE, Litt HI, Villines TC, Truong QA. R-SCAN: Cardiac CT Angiography for Acute Chest Pain. J Am Coll Radiol 2017; 14:1212-1214. [PMID: 28734685 DOI: 10.1016/j.jacr.2017.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 05/11/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri.
| | - Sebastian R McWilliams
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Judd E Hollander
- the Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Harold I Litt
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Todd C Villines
- Uniformed Services University School of Medicine, Bethesda, Maryland and Walter Reed National Military Medical Center, Bethesda, Maryland
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205
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Feng R, Tong J, Liu X, Zhao Y, Zhang L. High-Pitch Coronary CT Angiography at 70 kVp Adopting a Protocol of Low Injection Speed and Low Volume of Contrast Medium. Korean J Radiol 2017; 18:763-772. [PMID: 28860894 PMCID: PMC5552460 DOI: 10.3348/kjr.2017.18.5.763] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 02/22/2017] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the feasibility and image quality (IQ) of prospectively high-pitch coronary CT angiography (CCTA) with low contrast medium injection rate at 70 kVp. Materials and Methods One hundred and four patients with suspected coronary artery disease (body mass index < 26 kg/m2, sinus rhythm and heart rate < 70 beats/min) were prospectively enrolled and randomly divided into two groups. In group A and group B, 28 mL and 40 mL of 370 mgI/mL iodinated contrast media was administrated at a flow rate of 3.5 and 5 mL/s, respectively. CT values, noise, signal-to-noise ratio, contrast-to-noise ratio (CNR) of the proximal segments of coronary arteries and subjective IQ were evaluated. Results The CT values and noise in group A were significantly lower than those in group B (434–485 Hounsfield units [HU] vs. 772–851 HU, all p < 0.001; 17.8–22.3 vs. 23.3–26.4, all p < 0.005). The CNRs of the right coronary artery and left main artery showed no statistical difference between the two groups (42.1 ± 13.8 vs. 36.8 ± 16.0, p = 0.074; 38.7 ± 10.6 vs. 38.1 ± 17.0, p = 0.819). No statistical difference was observed between the two groups in IQ scores (3.04 ± 0.75 vs. 3.0 ± 0.79, p = 0.526) and diagnostic ratio (96.1% [50/52] vs. 94.2% [49/52], p = 0.647). Conclusion Prospective high-pitch CCTA at 70 kVp with 28 mL of contrast media and injection rate of 3.5 mL/s could provide diagnostic IQ for normal-weight patients with heart rate of < 70 beats/min.
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Affiliation(s)
- Ruiqi Feng
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang 110001, P.R. China
| | - Jiajie Tong
- Department of Radiology, Hebei General Hospital, Shijiazhuang 050051, P.R. China
| | - Xiaofei Liu
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang 110001, P.R. China
| | - Yu Zhao
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang 110001, P.R. China
| | - Liang Zhang
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang 110001, P.R. China
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206
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Hamilton-Craig C, Chan J. The clinical utility of new cardiac imaging modalities in Australasian clinical practice. Med J Aust 2017; 205:134-9. [PMID: 27465770 DOI: 10.5694/mja16.00438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/17/2016] [Indexed: 12/13/2022]
Abstract
Cardiac imaging is a rapidly evolving field, with improvements in the diagnostic capabilities of non-invasive cardiac assessment. We review the two main emerging technologies in cardiac imaging: computed tomography coronary angiography (CTCA) to evaluate chest symptoms and to exclude coronary artery disease; and cardiovascular magnetic resonance (CMR) for evaluating cardiac morphology, function and presence of scar. CTCA is an excellent "rule out" test, with a negative predictive value approaching 100%. Radiation exposure is no longer a concern for CTCA, with doses routinely < 5 mSv, and as low as < 1 mSv in selected patients. CTCA is useful for excluding coronary artery disease, investigating the anatomy of coronary anomalies or fistulae, and for the patency of coronary bypass grafts. CMR is the reference test for the accurate quantitation of left ventricular and right ventricular size and function. CMR has no ionising radiation, making it particularly suitable for patients with heart failure or congenital heart disease who require longitudinal follow-up. Evaluation of cardiomyopathies (hypertrophic, ischaemic, infiltrative, myocarditis, iron overload or idiopathic) is a unique strength of CMR. Stress perfusion CMR has a strong evidence base and improved spatial and temporal resolution compared with nuclear single-photon emission computed tomography.
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Affiliation(s)
| | - Jonathan Chan
- School of Medicine, Griffith University, Gold Coast, QLD
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207
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Abstract
Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.
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Affiliation(s)
- Nikhil Goyal
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Arthur Stillman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
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208
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Jin WY, Zhao XJ, Chen H. Decreased Diagnostic Accuracy of Multislice Coronary Computed Tomographic Angiography in Women with Atypical Angina Symptoms. Chin Med J (Engl) 2017; 129:2191-8. [PMID: 27625091 PMCID: PMC5022340 DOI: 10.4103/0366-6999.189908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Multislice computed tomography (MSCT) coronary angiography (CAG) is a noninvasive technique with a reported high diagnostic accuracy for coronary artery disease (CAD). Women, more frequently than men, are known to develop atypical angina symptoms. The purpose of this study was to investigate whether the diagnostic accuracy of MSCT in women with atypical presentation differs from that in men. Methods: We enrolled 396 in-hospital patients (141 women and 255 men) with suspected or proven CAD who successively underwent both MSCT and invasive CAG. CAD was defined as any coronary stenosis of ≥50% on conventional invasive CAG, which was used as the reference standard. The patients were divided into typical and atypical groups based on their symptoms of angina pectoris. The diagnostic accuracy of MSCT, including its sensitivity, specificity, negative predictive value, and positive predictive value (PPV), was calculated to determine the usefulness of MSCT in assessing stenoses. The diagnostic performance of MSCT was also assessed by constructing receiver operating characteristic (ROC) curves. Results: The PPV (91% vs. 97%, χ2 = 5.705, P < 0.05) and diagnostic accuracy (87% vs. 93%, χ2 = 5.093, P < 0.05) of MSCT in detecting CAD were lower in women than in men. Atypical presentation was an independent influencing factor on the diagnostic accuracy of MSCT in women (odds ratio = 4.94, 95% confidence intervals: 1.16–20.92, Walds = 4.69, P < 0.05). Compared with those in the atypical group, women with typical angina pectoris had higher PPV (98% vs. 74%, χ2 = 17.283. P < 0.001), diagnostic accuracy (93% vs. 72%, χ2 = 9.571, P < 0.001), and area under the ROC curve (0.91 vs. 0.64, Z = 2.690, P < 0.01) in MSCT diagnosis. Conclusions: Although MSCT is a reliable diagnostic modality for the exclusion of significant coronary artery stenoses in all patients, gender and atypical symptoms might have some influence on its diagnostic accuracy.
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Affiliation(s)
- Wen-Ying Jin
- Department of Cardiology, Peking University People's Hospital; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing 100044, China
| | - Xiu-Juan Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing 100044, China
| | - Hong Chen
- Department of Cardiology, Peking University People's Hospital; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing 100044, China
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209
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Ghoshhajra BB, Takx RAP, Staziaki PV, Vadvala H, Kim P, Neilan TG, Meyersohn NM, Bittner D, Janjua SA, Mayrhofer T, Greenwald JL, Truong QA, Abbara S, Brown DFM, Januzzi JL, Francis S, Nagurney JT, Hoffmann U. Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome. Eur Radiol 2017; 27:2784-2793. [PMID: 27885414 PMCID: PMC5976244 DOI: 10.1007/s00330-016-4562-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/03/2016] [Accepted: 08/11/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. METHODS Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. RESULTS One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. CONCLUSIONS Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. KEY POINTS • ED Coronary CTA using advanced systems is associated with low radiation exposure. • Negative coronary CTA is associated with low rates of MACE. • CTA in ED patients enables short median time to discharge home. • CTA strategy is characterized by few downstream tests including unnecessary ICA.
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Affiliation(s)
- Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA.
| | - Richard A P Takx
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pedro V Staziaki
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Harshna Vadvala
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Phillip Kim
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nandini M Meyersohn
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Daniel Bittner
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Medicine 2 - Cardiology, University Hospital Erlangen, Erlangen, Germany
| | - Sumbal A Janjua
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Jeffrey L Greenwald
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Quyhn A Truong
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Department of Radiology, Weill Cornell College of Medicine, New York, NY, USA
| | - Suhny Abbara
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Department Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, TX, USA
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sanjeev Francis
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
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210
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Dweck MR, Williams MC, Moss AJ, Newby DE, Fayad ZA. Computed Tomography and Cardiac Magnetic Resonance in Ischemic Heart Disease. J Am Coll Cardiol 2017; 68:2201-2216. [PMID: 27855810 PMCID: PMC5181647 DOI: 10.1016/j.jacc.2016.08.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/01/2016] [Accepted: 08/05/2016] [Indexed: 01/30/2023]
Abstract
Ischemic heart disease is a complex disease process caused by the development of coronary atherosclerosis, with downstream effects on the left ventricular myocardium. It is characterized by a long preclinical phase, abrupt development of myocardial infarction, and more chronic disease states such as stable angina and ischemic cardiomyopathy. Recent advances in computed tomography (CT) and cardiac magnetic resonance (CMR) now allow detailed imaging of each of these different phases of the disease, potentially allowing ischemic heart disease to be tracked during a patient’s lifetime. In particular, CT has emerged as the noninvasive modality of choice for imaging the coronary arteries, whereas CMR offers detailed assessments of myocardial perfusion, viability, and function. The clinical utility of these techniques is increasingly being supported by robust randomized controlled trial data, although the widespread adoption of cardiac CT and CMR will require further evidence of clinical efficacy and cost effectiveness.
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Affiliation(s)
- Marc R Dweck
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Alastair J Moss
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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211
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Shah R, Foldyna B, Hoffmann U. Outcomes of anatomical vs. functional testing for coronary artery disease : Lessons from the PROMISE trial. Herz 2017; 41:384-90. [PMID: 27333988 DOI: 10.1007/s00059-016-4451-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The development of coronary artery disease (CAD) is a major, final common pathway in heart disease worldwide. With a rise in stress testing and increased scrutiny on cost-effectiveness and radiation exposure in medical imaging, a focus on the relative merits of anatomic versus functional characterization of CAD has emerged. In this context, coronary computed tomography angiography (CCTA) is a noninvasive alternative to functional testing as a first-line test for CAD detection but is complimentary in its nature. Here, we discuss the design, results, and implications of the PROMISE trial, a randomized comparative effectiveness study of 10,003 patients across 193 sites in the United States and Canada comparing the prognostic and diagnostic power of CCTA and standard stress testing. Specifically, we discuss the safety (e. g., contrast, radiation exposure) of CCTA versus functional testing in CAD, the need for improved selection for noninvasive testing, the frequency of downstream testing after anatomic or functional imaging, the use of imaging results in clinical management, and novel modalities of CAD risk determination using CCTA. PROMISE demonstrated that in a real-world, low-to-intermediate risk patient population referred to noninvasive testing for CAD, both CCTA and functional testing approaches have similar clinical, economic, and safety-based outcomes. We conclude with open questions in CAD imaging, specifically as they pertain to the utilization of CCTA.
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Affiliation(s)
- R Shah
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, 02114, Boston, MA, USA
| | - B Foldyna
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, 02114, Boston, MA, USA
| | - U Hoffmann
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, 02114, Boston, MA, USA.
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212
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Bishop W, Girao G. Pragmatic approach to chest pain patients discharged with undetectable high-sensitivity troponin T and normal electrocardiogram: the STABS + CT protocol. Intern Med J 2017; 47:698-701. [PMID: 28580737 DOI: 10.1111/imj.13443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/06/2016] [Accepted: 11/13/2016] [Indexed: 11/30/2022]
Abstract
A strategy that discharges chest pain patients with negative high-sensitivity troponin and non-ischaemic electrocardiography changes may still result in 0.44% of patients experiencing myocardial infarction within 30 days. We observed that a pragmatic approach that systematically discharged 25 patients on cardio-protective medications of aspirin, metoprolol and atorvastatin followed with prompt (<10 days) coronary computed tomography angiography resulted in no major adverse cardiac event and adverse drug reaction 30 days post-presentation. The strategy resulted in three patients (12%) ultimately diagnosed with likely unstable angina, which required planned coronary intervention in two patients and medical management in one patient. No unplanned readmissions for chest pains were noted from initial presentation through to 6-month follow up.
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Affiliation(s)
- Warrick Bishop
- Calvary Cardiac Centre, Calvary Health Care Tasmania, Hobart, Tasmania, Australia
| | - Gary Girao
- Calvary Cardiac Centre, Calvary Health Care Tasmania, Hobart, Tasmania, Australia.,Department of Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
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213
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Stănescu A, Himcinschi E, Morariu M, Rat N, Bordi L, Rațiu M, Benedek A, Benedek I, Benedek T. Cardiac Computed Tomography Assessment in Acute Coronary Syndromes — Do We Have Time for It in Emergency Settings? JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The diagnosis and treatment of acute coronary syndrome remain a challenge for clinicians in many clinical settings, especially in patients with previous low-to-intermediate risk. Due to its high specificity and sensitivity for detecting significant coronary artery stenoses, cardiac computed tomography angiography (CCTA) tends to be used more frequently in the emergency room (ER) in the last years. This technique has been associated with a higher rate of safe discharge in patients with chest pain, less time spent in the ER, and decreased costs related to further investigations. In cases positive for coronary artery stenosis, CCTA can accurately evaluate the indication for percutaneous coronary angioplasty and can offer relevant information related to the characteristics of the coronary plaques, being able to detect vulnerable coronary plaques. The aim of this manuscript is to highlight the possibility of using CCTA in the ER in the assessment of patients with chest pain and to show the benefits of the procedure regarding safety, costs, accuracy, and time.
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Affiliation(s)
- Alexandra Stănescu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Elisabeta Himcinschi
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Mirabela Morariu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Nora Rat
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Lehel Bordi
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Mihaela Rațiu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | | | - Imre Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Theodora Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
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214
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Contijoch F, Stayman JW, McVeigh ER. The impact of small motion on the visualization of coronary vessels and lesions in cardiac CT: A simulation study. Med Phys 2017; 44:3512-3524. [PMID: 28432820 DOI: 10.1002/mp.12295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 02/27/2017] [Accepted: 04/16/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Coronary x-ray computed tomography angiography (CCTA) is used to non-invasively assess coronary artery geometry and has, combined with computational modeling, demonstrated the potential to identify physiologically significant lesions. These measurements require robust and accurate coronary imaging and delineation of vessels despite the presence of small motion. This simulation study characterizes the impact of small, uncorrected vessel drifts during data acquisition on the assessment of vessel intensity, diameter, and shape. METHODS We developed a digital phantom and simulated projection data for a clinical scanner geometry for a range of vessel drifts that can occur during relative vessel stasis (0 to 2 mm per 360° gantry rotation) for vessels between 0.2 and 3.0 mm in diameter (covering 0% through 93% stenosis of a 3 mm vessel). In addition to the impact of vessel drift, we evaluated the performance of half-scan acquisitions (relative to full-scans) over a range of gantry positions. The performance of FDK reconstructions was compared to an iterative technique and potential improvement in sampling from focal spot deflection and quarter detector offset was compared. RESULTS At rest, vessel intensity and diameter were accurately obtained in vessels greater than 1.5 mm with all vessels appearing circular in shape (major-to-minor axis ratio ~1). Vessels between 1.5 and 0.2 mm in diameter demonstrated a rapid decrease in signal intensity with full width half maximum (FWHM) vessel diameters remaining above 0.75 mm as true vessel diameter decreased. Uncorrected vessel motion resulted in decreased vessel intensity, increased vessel diameter, and distortion of vessel shape. The extent of these changes depended on both the position of the gantry as well as the reconstruction approach (half- vs. full-scan). FDK reconstruction results depended on choice of filter with Ram-Lak results yielding comparable performance to an unconstrained iterative reconstruction. Focal spot deflection and quarter detector offset did not result in large changes in performance, likely due to the high sampling density near the isocenter. CONCLUSIONS Despite improvement in gantry speed and acquisition of coronary images during cardiac phases that have relatively stationary vessels, small coronary drifts (0-2 mm per 360° rotation) have been reported and if uncorrected, can present challenges to visual grading and computational modeling of stenoses because vessels will appear dimmer, larger, and more ellipsoidal in shape. The impact of a particular motion depends on the gantry position, the use of half vs. full-scan acquisitions, and the reconstruction technique.
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Affiliation(s)
- Francisco Contijoch
- Department of Medicine, Division of Cardiology, UC San Diego School of Medicine, La Jolla, CA, 92123, USA
| | - J Webster Stayman
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Elliot R McVeigh
- Department of Medicine, Division of Cardiology, UC San Diego School of Medicine, La Jolla, CA, 92123, USA.,Department of Bioengineering, UC San Diego School of Engineering, La Jolla, CA, 92037-0412, USA.,Department of Radiology, UC San Diego School of Medicine, La Jolla, CA, 92123, USA
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215
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Liu T, Wang G, Li P, Dai X. Risk classification of highly sensitive troponin I predict presence of vulnerable plaque assessed by dual source coronary computed tomography angiography. Int J Cardiovasc Imaging 2017; 33:1831-1839. [PMID: 28528430 DOI: 10.1007/s10554-017-1174-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023]
Abstract
Patients presenting to the emergency department with acute chest pain, negative conventional troponin and electrocardiogram require serial testing to rule out acute coronary syndrome (ACS). We studied the association of highly sensitive troponin (hsTn) I with vulnerable plaque features as detected by coronary dual source computed tomography angiography (DSCTA) and determined whether hsTn I at the time of presentation combined with early DSCTA could improve classification of patients as high-risk or low risk for ACS. We included 220 patients with acute chest pain, negative electrocardiogram and conventional troponin who underwent DSCTA and had hsTn I measured at the time of presentation. The patients were categorized as having hsTn I below the limit of detection (low risk), intermediate and above the 99th percentile (high risk). Readers assessed DSCTA qualitatively for the presence of significant CAD (≥50% stenosis), calcified and non-calcified coronary plaque, and vulnerable plaque features (positive remodeling, low CT attenuation plaque, napkin-ring sign, spotty calcium). The mean age of the population was 50.3 ± 8.2 years (43% women). ACS during the index hospitalization occurred in 36 (16.3%) patients (myocardial infarction n = 8, unstable angina pectoris n = 28). HsTn I was below the limit of detection, intermediate, and above 99th percentile in 39 (17.7%), 139 (86.9%), and 42 (19.1%) patients, respectively. Across the categories of low risk, intermediate and high risk of hsTn I, there was increase in prevalence of ≥50% stenosis (0, 11.5, and 61.9% of patients; p < 0.001), any plaque (35.9, 51.1, and 85.7% of patients; p < 0.001) and high-risk plaque (0, 36.0, and 85.7% of patients; p < 0.001). None of the patients in low risk HsTn I group had ACS. ACS occurred in 10.1% of the intermediate hsTn I group and in 52.3% of the patients with high risk hsTnI group. Severity of stenosis and presence of vunerable plaque as detected by DSCTA are associated with increasing levels of hsTn I. DSCTA at the time of presentation with the assessment for both stenosis and high-risk plaque improved the diagnostic accuracy for ACS in the intermediate hsTn I group patients.
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Affiliation(s)
- Ting Liu
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Guan Wang
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Peiling Li
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Xu Dai
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China.
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216
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Dobra M, Bordi L, Nyulas T, Stănescu A, Morariu M, Condrea S, Benedek T. Clinical update. Computed Tomography — an Emerging Tool for Triple Rule-Out in the Emergency Department. A Review. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2017. [DOI: 10.1515/jce-2017-0005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Abstract
New imaging tools have been developed in recent years to rapidly and accurately diagnose life-threatening diseases associated with high mortality rates, such as acute coronary syndromes, acute aortic dissection, or pulmonary embolism. The concept of using computed tomographic (CT) assessment in emergency settings is based on the possibility of excluding multiple acute pathologies within one scan. It can be used for patients complaining of acute chest pain of unclear etiology with the possible association of acute coronary dissection or pulmonary embolism, but only a low to moderate risk of developing an acute coronary syndrome. One of the benefits of this protocol is the possibility of decreasing the number of patients who are hospitalized for further investigations. The technique also allows the rapid triage of patients and the safe discharge of those who show negative results. The aim of this review is to summarize the current medical literature regarding the potential use of CT for the triple rule-out (TRO) of coronary etiologies.
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Affiliation(s)
- Mihaela Dobra
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș , Romania
| | - Lehel Bordi
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș , Romania
| | - Tiberiu Nyulas
- University of Medicine and Pharmacy, Tîrgu Mureș , Romania
| | - Alexandra Stănescu
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș , Romania
| | - Mirabela Morariu
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș , Romania
| | - Sebastian Condrea
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș , Romania
| | - Theodora Benedek
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center, Tîrgu Mureș , Romania
- University of Medicine and Pharmacy, Tîrgu Mureș , Romania
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217
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Affiliation(s)
- Koen Nieman
- From the Department of Cardiovascular Medicine and Department of Radiology, Stanford School of Medicine, CA.
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218
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Korley FK, Gatsonis C, Snyder BS, George RT, Abd T, Zimmerman SL, Litt HI, Hollander JE. Clinical risk factors alone are inadequate for predicting significant coronary artery disease. J Cardiovasc Comput Tomogr 2017; 11:309-316. [PMID: 28487137 DOI: 10.1016/j.jcct.2017.04.011] [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: 09/23/2016] [Revised: 03/10/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We sought to derive and validate a model for identifying suspected ACS patients harboring undiagnosed significant coronary artery disease (CAD). METHODS This was a secondary analysis of data from a randomized control trial (RCT). Patients randomized to the CTA arm of an RCT examining a CTA-based strategy for ruling-out acute coronary syndrome (ACS) constitute the derivation cohort, which was randomly divided into a training dataset (2/3, used for model derivation) and a test dataset (1/3, used for internal validation (IV)). ED patients from a different center receiving CTA to evaluate for suspected ACS constitute the external validation (EV) cohort. Primary outcome was CTA-assessed significant CAD (stenosis of ≥50% in a major coronary artery). RESULTS In the derivation cohort, 11.2% (76/679) of subjects had CTA-assessed significant CAD, and in the EV cohort, 8.2% of subjects (87/1056) had CTA-assessed significant CAD. Age was the strongest predictor of significant CAD among the clinical risk factors examined. Predictor variables included in the derived logistic regression model were: age, sex, tobacco use, diabetes, and race. This model exhibited an area under the receiver operating characteristic curve (ROC AUC) of 0.72 (95% CI: 0.61-0.83) based on IV, and 0.76 (95% CI: 0.70, 0.82) based on EV. The derived random forest model based on clinical risk factors yielded improved but not sufficient discrimination of significant CAD (ROC AUC = 0.76 [95% CI: 0.67-0.85] based on IV). Coronary artery calcium score was a more accurate predictor of significant CAD than any combination of clinical risk factors (ROC AUC = 0.85 [95% CI: 0.76-0.94] based on IV; ROC AUC = 0.92 [95% CI: 0.88-0.95] based on EV). CONCLUSIONS Clinical risk factors, either individually or in combination, are insufficient for accurately identifying suspected ACS patients harboring undiagnosed significant coronary artery disease.
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Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Constantine Gatsonis
- Center for Statistical Sciences and Department of Biostatistics, Brown University School of Public Health, Providence, RI, United States.
| | - Bradley S Snyder
- Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, United States.
| | - Richard T George
- Adjunct Faculty, Division of Cardiology, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Thura Abd
- Division of Cardiology, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Stefan L Zimmerman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Harold I Litt
- Department of Radiology and Division of Cardiovascular Medicine, Department of Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States.
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States.
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219
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Non-gated high-pitch computed tomography aortic angiography: Myocardial perfusion defects in patients with suspected aortic dissection. J Cardiovasc Comput Tomogr 2017; 11:208-212. [DOI: 10.1016/j.jcct.2017.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/20/2017] [Accepted: 04/11/2017] [Indexed: 11/22/2022]
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220
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Bittner DO, Mayrhofer T, Bamberg F, Hallett TR, Janjua S, Addison D, Nagurney JT, Udelson JE, Lu MT, Truong QA, Woodard PK, Hollander JE, Miller C, Chang AM, Singh H, Litt H, Hoffmann U, Ferencik M. Impact of Coronary Calcification on Clinical Management in Patients With Acute Chest Pain. Circ Cardiovasc Imaging 2017; 10:e005893. [PMID: 28487318 PMCID: PMC5901678 DOI: 10.1161/circimaging.116.005893] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/28/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS). METHODS AND RESULTS This is a pooled analysis of ACRIN-PA (American College of Radiology Imaging Network-Pennsylvania) 4005 and the ROMICAT-II trial (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost, and diagnostic yield to identify patients with obstructive coronary artery disease on subsequent invasive coronary angiography across CAC score strata (Agatston score: 0, >0-10, >10-100, >100-400, >400). Out of 1234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive coronary artery disease (≥70% stenosis) and 68 (5.5%) had ACS. Prevalence of obstructive coronary artery disease (1%-64%), ACS (1%-44%), downstream testing (4%-72%), and total (2337-8484 US$) and diagnostic cost (2310-6678 US$) increased across CAC strata (P<0.001). As the increase in testing and cost were lower than the increase of ACS rate in patients with CAC>400, cost to diagnose one ACS was lowest in this group (19 283 US$ versus 464 399 US$) as compared with patients without CAC. The diagnostic yield of invasive coronary angiography was highest in patients with CAC>400 (87% versus 38%). CONCLUSIONS Downstream testing, total, and diagnostic cost increased with increasing CAC, but were found to be appropriate because obstructive coronary artery disease and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost-efficient testing and excellent diagnostic yield can be achieved even with high CAC burden. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01084239 and NCT00933400.
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Affiliation(s)
- Daniel O Bittner
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.).
| | - Thomas Mayrhofer
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Fabian Bamberg
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Travis R Hallett
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Sumbal Janjua
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Daniel Addison
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - John T Nagurney
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - James E Udelson
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Michael T Lu
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Quynh A Truong
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Pamela K Woodard
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Judd E Hollander
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Chadwick Miller
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Anna Marie Chang
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Harjit Singh
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Harold Litt
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Udo Hoffmann
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
| | - Maros Ferencik
- From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.)
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Abstract
Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.
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Lu MT, Ferencik M, Roberts RS, Lee KL, Ivanov A, Adami E, Mark DB, Jaffer FA, Leipsic JA, Douglas PS, Hoffmann U. Noninvasive FFR Derived From Coronary CT Angiography: Management and Outcomes in the PROMISE Trial. JACC Cardiovasc Imaging 2017; 10:1350-1358. [PMID: 28412436 DOI: 10.1016/j.jcmg.2016.11.024] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/12/2016] [Accepted: 11/17/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The purpose of this study was to determine whether noninvasive fractional flow reserve derived from computed tomography (FFRCT) predicts coronary revascularization and outcomes and whether its addition improves efficiency of referral to invasive coronary angiography (ICA) after coronary computed tomography angiography (CTA). BACKGROUND FFRCT may improve the efficiency of an anatomic CTA strategy for stable chest pain. METHODS This observational cohort study included patients with stable chest pain in the PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial referred to ICA within 90 days after CTA. FFRCT was measured at a blinded core laboratory, and FFRCT results were unavailable to caregivers. We determined the agreement of FFRCT (positive if ≤0.80) with stenosis on CTA and ICA (positive if ≥50% left main or ≥70% other coronary artery), and predictive value for a composite of coronary revascularization or major adverse cardiac events (death, myocardial infarction, or unstable angina). We retrospectively assessed whether adding FFRCT ≤0.80 as a gatekeeper could improve efficiency of referral to ICA, defined as decreased rate of ICA without ≥50% stenosis and increased ICA leading to revascularization. RESULTS FFRCT was calculated in 67% (181 of 271) of eligible patients (mean age 62 years; 36% women). FFRCT was discordant with stenosis in 31% (57 of 181) for CTA and 29% (52 of 181) for ICA. Most patients undergoing coronary revascularization had an FFRCT of ≤0.80 (91%; 80 of 88). An FFRCT of ≤0.80 was a significantly better predictor for revascularization or major adverse cardiac events than severe CTA stenosis (HR: 4.3 [95% confidence interval [CI]: 2.4 to 8.9] vs. 2.9 [95% CI: 1.8 to 5.1]; p = 0.033). Reserving ICA for patients with an FFRCT of ≤0.80 could decrease ICA without ≥50% stenosis by 44%, and increase the proportion of ICA leading to revascularization by 24%. CONCLUSIONS In this hypothesis-generating study of patients with stable chest pain referred to ICA from CTA, an FFRCT of ≤0.80 was a better predictor of revascularization or major adverse cardiac events than severe stenosis on CTA. Adding FFRCT may improve efficiency of referral to ICA from CTA alone.
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Affiliation(s)
- Michael T Lu
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Maros Ferencik
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Oregon Health & Science University, Portland, Oregon
| | - Rhonda S Roberts
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Alexander Ivanov
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Adami
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Farouc A Jaffer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jonathon A Leipsic
- Department of Radiology, St Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Udo Hoffmann
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Chung HW, Ko SM, Hwang HK, So Y, Yi JG, Lee EJ. Diagnostic Performance of Coronary CT Angiography, Stress Dual-Energy CT Perfusion, and Stress Perfusion Single-Photon Emission Computed Tomography for Coronary Artery Disease: Comparison with Combined Invasive Coronary Angiography and Stress Perfusion Cardiac MRI. Korean J Radiol 2017; 18:476-486. [PMID: 28458600 PMCID: PMC5390617 DOI: 10.3348/kjr.2017.18.3.476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 09/07/2016] [Indexed: 12/24/2022] Open
Abstract
Objective To investigate the diagnostic performance of coronary computed tomography angiography (CCTA), stress dual-energy computed tomography perfusion (DE-CTP), stress perfusion single-photon emission computed tomography (SPECT), and the combinations of CCTA with myocardial perfusion imaging (CCTA + DE-CTP and CCTA + SPECT) for identifying coronary artery stenosis that causes myocardial hypoperfusion. Combined invasive coronary angiography (ICA) and stress perfusion cardiac magnetic resonance (SP-CMR) imaging are used as the reference standard. Materials and Methods We retrospectively reviewed the records of 25 patients with suspected coronary artery disease, who underwent CCTA, DE-CTP, SPECT, SP-CMR, and ICA. The reference standard was defined as ≥ 50% stenosis by ICA, with a corresponding myocardial hypoperfusion on SP-CMR. Results For per-vascular territory analysis, the sensitivities of CCTA, DE-CTP, SPECT, CCTA + DE-CTP, and CCTA + SPECT were 96, 96, 68, 93, and 68%, respectively, and specificities were 72, 75, 89, 85, and 94%, respectively. The areas under the receiver operating characteristic curve (AUCs) were 0.84 ± 0.05, 0.85 ± 0.05, 0.79 ± 0.06, 0.89 ± 0.04, and 0.81 ± 0.06, respectively. For per-patient analysis, the sensitivities of CCTA, DE-CTP, SPECT, CCTA + DE-CTP, and CCTA + SPECT were 100, 100, 89, 100, and 83%, respectively; the specificities were 14, 43, 57, 43, and 57%, respectively; and the AUCs were 0.57 ± 0.13, 0.71 ± 0.11, 0.73 ± 0.11, 0.71 ± 0.11, and 0.70 ± 0.11, respectively. Conclusion The combination of CCTA and DE-CTP enhances specificity without a loss of sensitivity for detecting hemodynamically significant coronary artery stenosis, as defined by combined ICA and SP-CMR.
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Affiliation(s)
- Hyun Woo Chung
- Department of Nuclear Medicine, Konkuk University Medical Center, Research Institute of Biomedical Science, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Research Institute of Biomedical Science, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Hweung Kon Hwang
- Department of Internal Medicine, Division of Cardiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Young So
- Department of Nuclear Medicine, Konkuk University Medical Center, Research Institute of Biomedical Science, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Jeong Geun Yi
- Department of Radiology, Konkuk University Medical Center, Research Institute of Biomedical Science, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Eun Jeong Lee
- Department of Nuclear Medicine, Seoul Medical Center, Seoul 02053, Korea
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224
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Abstract
Coronary computed tomography angiography (CCTA) plays an important role in many specific scenarios such as in symptomatic patients with intermediate pretest of coronary artery disease (CAD), as well as in the triage of patients with acute chest pain with TIMI risk ≤2. However, it cannot detect the presence of associated ischemia, which is critical for clinical decision making among patients with moderate to severe stenosis. Although functional information can be obtained with different non-invasive tools, cardiac CT is the unique modality that can perform a comprehensive evaluation of coronary anatomy plus the functional significance of lesions. Myocardial CT perfusion (CTP) can be performed with different approaches such as static and dynamic CTP. In addition, static CTP can be performed using single energy CT (SECT) or dual energy CT (DECT). In this review, we will discuss the technical parameters and the available clinical evidence of static CTP using both SECT and DECT.
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Affiliation(s)
- Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
| | - Carlos Capunay
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
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Lau GTE, Wei H, Wickham J, To ACY. The Significance of Equivocal Exercise Treadmill ECG for Intermediate Risk Chest Pain Assessment - Insight From Coronary CT Angiography Data. Heart Lung Circ 2017; 27:50-57. [PMID: 28320636 DOI: 10.1016/j.hlc.2017.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 01/20/2017] [Accepted: 01/26/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Exercise treadmill test (ETT) is commonly the first-line investigation in troponin-negative chest pain patients. Inconclusive results are common and often lead to repeated functional testings. Coronary computed tomographic angiography (CCTA) has excellent negative predictive value for coronary artery disease detection and may play an important role in their diagnostic workup. We aim to analyse ETT and CCTA findings to understand their modern roles in intermediate risk chest pain population with inconclusive ETT. METHODS Patients who underwent both ETT and CCTA at our institution between August 2011 and February 2013 were retrospectively investigated. The ETTs were blindly reviewed, with equivocal ETTs defined as any indeterminate results not strictly adhering to ACC/AHA guidelines for positive ETT. Baseline demographics, clinical characteristics and investigation results were collated. Follow-up outcome data for subsequent investigations, representations, major cardiac adverse events (MACE) and unexpected revascularisations were also analysed. RESULTS 346 consecutive patients were identified (age 57±10years, 53% females, body mass index (BMI) 28±4, Dukes Clinical Score 48±30%, mean follow-up 2.1±0.4years). The ETT was positive in 31%, equivocal in 54% and negative in 15%. Obstructive coronary artery disease (CAD) prevalence was 25% (29% males, 13% females). Those with negative ETTs had obstructive CAD in 8%, with no adverse outcomes during follow-up. Obstructive CAD was seen in 20% with "equivocal" ETTs and 29% with "positive" ETTs. In females, obstructive CAD prevalence was low, and similar in those with equivocal or positive ETT (16% and 11% respectively). In males, obstructive CAD was almost 50% in those with positive ETT (p=0.005). CONCLUSIONS Obstructive CAD was found in one in five "equivocal" ETTs, hence, not all should be considered negative. Obstructive CAD was only found in one in three "positive" ETTs, hence not all should proceed to invasive angiography. CCTA may be an important gatekeeper test in those with low-intermediate pre-test probability of obstructive CAD.
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Affiliation(s)
- Gary T E Lau
- Cardiovascular Division, North Shore Hospital, Auckland, New Zealand
| | - Henry Wei
- Cardiovascular Division, North Shore Hospital, Auckland, New Zealand
| | - Jo Wickham
- Cardiovascular Division, North Shore Hospital, Auckland, New Zealand
| | - Andrew C Y To
- Cardiovascular Division, North Shore Hospital, Auckland, New Zealand.
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Meyersohn NM, Szilveszter B, Staziaki PV, Scholtz JE, Takx RAP, Hoffmann U, Ghoshhajra BB. Coronary CT angiography in the emergency department utilizing second and third generation dual source CT. J Cardiovasc Comput Tomogr 2017; 11:249-257. [PMID: 28506470 DOI: 10.1016/j.jcct.2017.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/17/2017] [Accepted: 03/19/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Coronary computed tomography angiography (coronary CTA) allows efficient triage of low to intermediate risk patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). Techniques for coronary CTA acquisition in the ED continue to evolve with the establishment of standardized scan protocols and the introduction of newer generations of CT hardware. OBJECTIVES To evaluate qualitative and quantitative image quality and radiation dose exposure of coronary CTA acquired on 2nd versus 3rd generation dual source CT (DSCT) scanners using a standardized institutional scan protocol designed for the ED. METHODS A retrospective observational case-control study was performed of 246 ED patients referred to coronary CTA with suspicion of ACS (56.5% male; mean age 53.3 ± 11.6 years) between October 2013 and August 2015.123 consecutive patients were scanned on 3rd generation DSCT, and a cohort of 123 patients matched by age, BMI and heart rate were identified who had undergone 2nd generation DSCT imaging utilizing the same standard clinical protocol. Qualitative and quantitative image quality parameters and radiation exposures were evaluated. RESULTS Qualitative image quality was significantly higher using 3rd generation DSCT as compared to 2nd generation (p < 0.001). Mean attenuation in the proximal coronary arteries was also significantly higher on 3rd generation DSCT than for 2nd generation (586 HU vs. 426 HU in the left main coronary artery (LM), p < 0.001). Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) values, however, were lower in 3rd generation DSCT than 2nd generation (SNR 11.2 [9.9-13.4] vs 13.5 [11.0-15.5] and CNR 12.4 [10.9-14.8] vs 15.2 [12.8-17.9] in the LM, p < 0.001). Median effective dose was also lower for 3rd generation DSCT than for 2nd generation (2.9 [2.3-5.0] mSv and 3.7 mSv [2.5-5.7], respectively) although this trend did not reach statistical significance (p = 0.065). CONCLUSION Qualitative image quality and mean CT attenuation values of the assessed coronary segments were significantly higher using 3rd generation DSCT. SNR and CNR were lower on 3rd generation DSCT, however this was accompanied by a trend toward lower radiation dose exposure when using the same standard institutional protocol.
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Affiliation(s)
- Nandini M Meyersohn
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
| | - Balint Szilveszter
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Pedro V Staziaki
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jan-Erik Scholtz
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Richard A P Takx
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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227
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Trials of Imaging Use in the Emergency Department for Acute Chest Pain. JACC Cardiovasc Imaging 2017; 10:338-349. [DOI: 10.1016/j.jcmg.2016.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023]
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Noninvasive Testing in Emergency Department Patients with Low-Risk Chest Pain: Does the Evidence Support Current Guidelines? Cardiol Rev 2017; 24:268-272. [PMID: 26544635 DOI: 10.1097/crd.0000000000000096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients who present to the emergency department with chest pain but no evidence of ischemia on the electrocardiogram and negative cardiac markers are at very low risk. The newest American Heart Association/American College of Cardiology guidelines give noninvasive cardiac testing a IIa recommendation in this patient population. Here, we will review the existing literature that was cited in the American Heart Association/American College of Cardiology document, as well as several large, contemporary, comparative observational studies which were not included to address the following question: Do the benefits of noninvasive cardiac testing in this patient population outweigh the risks?
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Thrall JH. Trends and Developments Shaping the Future of Diagnostic Medical Imaging: 2015 Annual Oration in Diagnostic Radiology. Radiology 2016; 279:660-6. [PMID: 27183401 DOI: 10.1148/radiol.2016160293] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- James H Thrall
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 25 New Chardon St, Suite 400, Boston, MA 02114
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230
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Hollander JE, Than M, Mueller C. State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes. Circulation 2016; 134:547-64. [PMID: 27528647 DOI: 10.1161/circulationaha.116.021886] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.
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Affiliation(s)
- Judd E Hollander
- From Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (J.E.H.); Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand (M.T.); and Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland (C.M.)
| | - Martin Than
- From Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (J.E.H.); Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand (M.T.); and Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland (C.M.)
| | - Christian Mueller
- From Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (J.E.H.); Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand (M.T.); and Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland (C.M.)
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Abstract
OBJECTIVE The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients. METHODS For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared. RESULTS Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21). CONCLUSIONS Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.
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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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Foy AJ, Dhruva SS, Mandrola J. For the Patient with "Low-risk Chest Pain"-How Low Is Low? Acad Radiol 2016; 23:1587-1591. [PMID: 27671908 DOI: 10.1016/j.acra.2016.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/10/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Andrew J Foy
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Mail Code H047, 500 University Drive, P.O. Box 850, Hershey, PA 17033; Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
| | - Sanket S Dhruva
- Department of Medicine, Robert Wood Johnson Foundation Clinical Scholars Program, Yale University, New Haven, Connecticut
| | - John Mandrola
- Cardiology Division, Baptist Health Louisville, Louisville, Kentucky
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Jha S. Fighting Small Numbers. Acad Radiol 2016; 23:1467-1469. [PMID: 27776998 DOI: 10.1016/j.acra.2016.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Saurabh Jha
- University of Pennsylvania, Philadelphia, PA 19104.
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The Potential Role of Combined Highly Sensitive Troponin and Coronary Computed Tomography Angiography in the Evaluation of Patients with Suspected Acute Coronary Syndrome in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lalude OO, Pugliese F, de Feyter PJ, Lerakis S. Complementary Imaging Techniques. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | | | - Stamatios Lerakis
- Emory University School of Medicine and Georgia Institute of Technology; Atlanta GA USA
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Chahal H, Levsky JM, Garcia MJ. Cardiac CT: present and future applications. BRITISH HEART JOURNAL 2016; 102:1840-1850. [DOI: 10.1136/heartjnl-2015-307481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ropp A, White C. Current and Future Applications of Coronary CT Angiography with and Without FFR in the Emergency Room. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9391-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nudi F, Lotrionte M, Biasucci LM, Peruzzi M, Marullo AG, Frati G, Valenti V, Giordano A, Biondi-Zoccai G. Comparative safety and effectiveness of coronary computed tomography: Systematic review and meta-analysis including 11 randomized controlled trials and 19,957 patients. Int J Cardiol 2016; 222:352-358. [PMID: 27500763 DOI: 10.1016/j.ijcard.2016.07.269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/26/2016] [Accepted: 07/30/2016] [Indexed: 02/08/2023]
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Penagaluri A, Higgins AY, Vavere AL, Miller JM, Arbab-Zadeh A, Betoko A, Steveson C, Zimmermann E, Cox C, Rochitte CE, Dewey M, Kofoed KF, Niinuma H, Di Carli MF, Lima JA, Chen MY. Computed Tomographic Perfusion Improves Diagnostic Power of Coronary Computed Tomographic Angiography in Women. Circ Cardiovasc Imaging 2016; 9:CIRCIMAGING.116.005189. [DOI: 10.1161/circimaging.116.005189] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/26/2016] [Indexed: 11/16/2022]
Abstract
Background—
Coronary computed tomographic angiography (CTA) and myocardial perfusion imaging (CTP) is a validated approach for detection and exclusion of flow-limiting coronary artery disease (CAD), but little data are available on gender-specific performance of these modalities. In this study, we aimed to evaluate the diagnostic accuracy of combined coronary CTA and CTP in detecting flow-limiting CAD in women compared with men.
Methods and Results—
Three hundred and eighty-one patients who underwent both CTA-CTP and single-photon emission computed tomography myocardial perfusion imaging preceding invasive coronary angiography as part of the CORE320 multicenter study (Coronary Artery Evaluation Using 320-row Multidetector Computed Tomography Angiography and Myocardial Perfusion) were included in this ancillary study. All 4 image modalities were analyzed in blinded, independent core laboratories. Prevalence of flow-limiting CAD defined by invasive coronary angiography equal to 50% or greater with an associated single-photon emission computed tomography myocardial perfusion imaging defect was 45% (114/252) and 23% (30/129) in males and females, respectively. Patient-based diagnostic accuracy defined by the area under the receiver operating curve for detecting flow-limiting CAD by CTA alone in females was 0.83 (0.75–0.89) and for CTA-CTP was 0.92 (0.86–0.97;
P
=0.003) compared with men where the area under the receiver operating curve for detecting flow-limiting CAD by CTA alone was 0.82 (0.77–0.87) and for CTA-CTP was 0.84 (0.80–0.89;
P
=0.29).
Conclusions—
The combination of CTA-CTP was performed similarly in men and women for identifying flow-limiting coronary stenosis; however, in women, CTP had incremental value over CTA alone, which was not the case in men.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00934037.
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Affiliation(s)
- Ashritha Penagaluri
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Angela Y. Higgins
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Andrea L. Vavere
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Julie M. Miller
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Armin Arbab-Zadeh
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Aisha Betoko
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Chloe Steveson
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Elke Zimmermann
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Christopher Cox
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Carlos E. Rochitte
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Marc Dewey
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Klaus F. Kofoed
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Hiroyuki Niinuma
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Marcelo F. Di Carli
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - João A.C. Lima
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
| | - Marcus Y. Chen
- From the Johns Hopkins Hospital and School of Medicine (A.P., A.L.V., J.M.M., A.A.-Z, J.A.C.L.) and Johns Hopkins Bloomberg School of Public Health (A.B., C.C.), Baltimore, MD; National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD (A.Y.H., M.Y.C.); Toshiba Medical Systems Corporation, Japan (C.S); Charité Medical School, Humboldt, Berlin, Germany (E.Z., M.D.); Heart Institute, InCor, University of São Paulo Medical School, Brazil (C.E.R.); Rigshospitalet, University of
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243
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Markham R, Murdoch D, Walters DL, Hamilton-Craig C. Coronary computed tomography angiography and its increasing application in day to day cardiology practice. Intern Med J 2016; 46:29-34. [PMID: 26813899 DOI: 10.1111/imj.12960] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/22/2015] [Accepted: 10/22/2015] [Indexed: 12/22/2022]
Abstract
Coronary artery disease (CAD) is the leading single cause of death in Australia affecting around 1.4 million people. Coronary computed tomography angiography has an established role in the assessment of patients with low to intermediate pretest probability for CAD who have chest pain and is typically used with the aim to rule out significant coronary artery stenosis. Use was initially limited because of concerns over radiation exposure, a Medicare rebate restricted to specialist referrals and an absence of data supporting its use as an alternative to functional testing in patients with chest pain. Recent advances in scanner technology and image sequencing, along with data from randomised control trials, have addressed these issues and indicate that coronary computed tomography angiography will play a greater role in the assessment of CAD in the coming years.
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Affiliation(s)
- R Markham
- Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - D Murdoch
- Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - D L Walters
- Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - C Hamilton-Craig
- Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia.,University of Washington, Seattle, Washington, USA
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Kühl JT, Kristensen TS, Thomsen AF, Hindsø L, Hansen KL, Nielsen OW, Kelbæk H, Kofoed KF. Clinical and prognostic correlates of pulmonary congestion in coronary computed tomography angiography data sets. J Cardiovasc Comput Tomogr 2016; 10:466-472. [PMID: 27717753 DOI: 10.1016/j.jcct.2016.09.002] [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: 05/26/2016] [Revised: 09/09/2016] [Accepted: 09/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Signs of pulmonary congestion obtained from cardiac computed tomography angiographic (coronary CTA) images have not previously been related to clinical congestion or outcome and the clinical value is, therefore, unknown. Our objective was to test the hypothesis that signs of pulmonary congestion predict clinical heart failure and adverse outcome in patients with myocardial infarction. METHODS Coronary CTA was performed before invasive treatment in 400 prospectively included patients with non ST segment elevation myocardial infarction in an observational study. Using a previously described chest computed tomography evaluation algorithm, patients were classified as having "no congestion", "mild to moderate congestion" or "severe congestion". RESULTS Using multivariate analyses, presence of pulmonary congestion on coronary CTA images was associated with age, female gender, left ventricular ejection fraction (LVEF) and left atrial size. The diagnostic accuracy for predicting clinical heart failure, defined as Killip class >1, was: sensitivity: 83%, specificity: 69%, positive predictive value: 25%, and negative predictive value: 97%. The median follow-up time was 50 months and the study end-point of death or hospitalization due to heart failure was reached in 68 (16%) patients. In a Cox proportional hazards model with adjustments for known risk factors and Killip class, the presence of "mild to moderate congestion" and "severe congestion" was independently associated with adverse outcome (Hazard ratio: 2.6 (95% CI:1.3-5.0) and 3.2 (1.3-7.5)). CONCLUSION Signs of pulmonary congestion on coronary CTA images are closely correlated to cardiac dysfunction, predict clinical heart failure, and provide prognostic value independent of LVEF and Killip class.
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Affiliation(s)
- J Tobias Kühl
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark.
| | - Thomas S Kristensen
- Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Anna F Thomsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Louise Hindsø
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Kristoffer L Hansen
- Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Olav W Nielsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | - Henning Kelbæk
- Department of Cardiology, Roskilde Sygehus, Roskilde, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark; Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Denmark
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245
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Long B, Koyfman A. Best Clinical Practice: Current Controversies in Evaluation of Low-Risk Chest Pain-Part 1. J Emerg Med 2016; 51:668-676. [PMID: 27693075 DOI: 10.1016/j.jemermed.2016.07.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chest pain is a common presentation to the emergency department (ED), though the majority of patients are not diagnosed with acute coronary syndrome (ACS). Many patients are admitted to the hospital due to fear of ACS. OBJECTIVE Our aim was to investigate controversies in low-risk chest pain evaluation, including risk of missed ACS, stress test, and coronary computed tomography angiography (CCTA). DISCUSSION Chest pain accounts for 10 million ED visits in the United States annually. Many patients are at low risk for a major cardiac adverse event (MACE). With negative troponin and nonischemic electrocardiogram (ECG), the risk of MACE and myocardial infarction (MI) is < 1%. The American Heart Association recommends further evaluation in low- to intermediate-risk patients within 72 h. These modalities add little to further risk stratification. These evaluations do not appropriately risk stratify patients who are already at low risk, nor do they diagnose acute MI. CCTA is an anatomic evaluation of the coronary vasculature with literature support to decrease ED length of stay, though it is associated with downstream testing. Literature is controversial concerning further risk stratification in already low-risk patients. CONCLUSIONS With nonischemic ECG and negative cardiac biomarker, the risk of ACS approaches < 1%. Use of stress test and CCTA for risk stratification of low-risk chest pain patients is controversial. These tests may allow prognostication but do not predict ACS risk beyond ECG and troponin. CCTA may be useful for intermediate-risk patients, though further studies are required.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
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246
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Chinnaiyan KM, Raff GL. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:62. [DOI: 10.1007/s11936-016-0484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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247
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Sørgaard M, Linde JJ, Hove JD, Petersen JR, Jørgensen TBS, Abdulla J, Heitmann M, Kragelund C, Hansen TF, Udholm PM, Pihl C, Kühl JT, Engstrøm T, Jensen JS, Høfsten DE, Kelbæk H, Kofoed KF. Myocardial perfusion 320-row multidetector computed tomography-guided treatment strategy for the clinical management of patients with recent acute-onset chest pain: Design of the CArdiac cT in the treatment of acute CHest pain (CATCH)-2 randomized controlled trial. Am Heart J 2016; 179:127-35. [PMID: 27595687 DOI: 10.1016/j.ahj.2016.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 05/27/2016] [Indexed: 12/21/2022]
Abstract
AIMS Patients admitted with chest pain are a diagnostic challenge because the majority does not have coronary artery disease (CAD). Assessment of CAD with coronary computed tomography angiography (CCTA) is safe, cost-effective, and accurate, albeit with a modest specificity. Stress myocardial computed tomography perfusion (CTP) has been shown to increase the specificity when added to CCTA, without lowering the sensitivity. This article describes the design of a randomized controlled trial, CATCH-2, comparing a clinical diagnostic management strategy of CCTA alone against CCTA in combination with CTP. METHODS Patients with acute-onset chest pain older than 50 years and with at least one cardiovascular risk factor for CAD are being prospectively enrolled to this study from 6 different clinical sites since October 2013. A total of 600 patients will be included. Patients are randomized 1:1 to clinical management based on CCTA or on CCTA in combination with CTP, determining the need for further testing with invasive coronary angiography including measurement of the fractional flow reserve in vessels with coronary artery lesions. Patients are scanned with a 320-row multidetector computed tomography scanner. Decisions to revascularize the patients are taken by the invasive cardiologist independently of the study allocation. The primary end point is the frequency of revascularization. Secondary end points of clinical outcome are also recorded. DISCUSSION The CATCH-2 will determine whether CCTA in combination with CTP is diagnostically superior to CCTA alone in the management of patients with acute-onset chest pain.
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Affiliation(s)
- Mathias Sørgaard
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Jesper J Linde
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Hove
- Department of Cardiology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jan R Petersen
- Department of Cardiology, Amager Hospital, Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Tem B S Jørgensen
- Department of Cardiology, Amager Hospital, Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Jawdat Abdulla
- Department of Medicine, Division of Cardiology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Merete Heitmann
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Kragelund
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Fritz Hansen
- Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Patricia M Udholm
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Pihl
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - J Tobias Kühl
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jan Skov Jensen
- Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Dan E Høfsten
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henning Kelbæk
- Department of Cardiology, Roskilde Sygehus, University of Copenhagen, Copenhagen, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, The Diagnostic Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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248
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Morris JR, Bellolio MF, Sangaralingham LR, Schilz SR, Shah ND, Goyal DG, Bell MR, Kopecky SL, Gilani WI, Hess EP. Comparative Trends and Downstream Outcomes of Coronary Computed Tomography Angiography and Cardiac Stress Testing in Emergency Department Patients With Chest Pain: An Administrative Claims Analysis. Acad Emerg Med 2016; 23:1022-30. [PMID: 27155236 DOI: 10.1111/acem.13005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the emergency department (ED). We assessed trends in CCTA use and compared downstream healthcare utilization between CCTA and cardiac stress testing modalities. METHODS Using administrative claims data (Optum Labs Data Warehouse) from over 100 million geographically diverse privately insured and Medicare Advantage enrollees across the United States, we identified 2,047,799 ED patients from January 2006 to December 2013 who presented with chest pain and had a CCTA or cardiac stress test within 72 hours. Cohorts were established based on CCTA or functional stress testing (myocardial perfusion scintigraphy [MPS], stress echocardiogram [SE], or treadmill exercise electrocardiogram [TMET]) performed within 72 hours of the ED visit. We tracked subsequent invasive cardiac procedures (invasive coronary angiography [ICA], percutaneous coronary intervention [PCI], and coronary artery bypass grafting [CABG]), repeat noninvasive testing, return ED visits, hospitalization, and the rate of acute myocardial infarction (AMI) within 30 days. We used propensity-score matching to adjust for coronary artery disease (CAD) risk factors, Charlson-Deyo comorbidity index, and baseline differences between patients selected for CCTA or cardiac stress testing. Logistic regression was used to measure adjusted associations between testing modality and outcomes. RESULTS During the study period, CCTA use increased from 0.8% to 4.5% of all cardiac testing within 72 hours, a change of 434% (p-value for trend < 0.001), while rates of other cardiac stress testing modalities decreased (-22% for TMET [p < 0.001]; -11% for SE [p = 0.11]; -6% for MPS [p = 0.04]. After matching, there was no difference in the 30-day rate of AMI between testing modalities. Compared to MPS, CCTA was associated with higher rates of PCI (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.04 to 1.51), and CABG (OR = 1.47; 95% CI = 1.03 to 2.13). Compared to SE and treadmill stress testing, CCTA was associated with more invasive procedures, hospitalizations, return ED visits, and repeat noninvasive testing. CONCLUSIONS CCTA use increased fourfold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits. The authors have no relevant financial information or potential conflicts to disclose.
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Affiliation(s)
- Jacob R Morris
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN
| | - M Fernanda Bellolio
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Stephanie R Schilz
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
- Optum Labs, Cambridge, MA
| | - Deepi G Goyal
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Waqas I Gilani
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Erik P Hess
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN.
- Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN.
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249
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Shiran A, Blondheim DS, Shimoni S, Jabarren M, Rosenmann D, Sagie A, Leibowitz D, Leitman M, Feinberg M, Beeri R, Adawi S, Shotan A, Goland S, Bloch L, Kobal SL, Liel-Cohen N. Two-dimensional strain echocardiography for diagnosing chest pain in the emergency room: a multicentre prospective study by the Israeli echo research group. Eur Heart J Cardiovasc Imaging 2016; 18:1016-1024. [DOI: 10.1093/ehjci/jew168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/18/2016] [Indexed: 11/13/2022] Open
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250
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Newby DE, Gray AJ. CATCH a Glimpse of the Future. JACC Cardiovasc Imaging 2016; 8:1414-1416. [PMID: 26699110 DOI: 10.1016/j.jcmg.2015.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/06/2015] [Indexed: 11/28/2022]
Affiliation(s)
- David E Newby
- Department of Cardiology, Royal Infirmary, and University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom.
| | - Alasdair J Gray
- Department of Cardiology, Royal Infirmary, and University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
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