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Avram R, Olgin JE, Ahmed Z, Verreault-Julien L, Wan A, Barrios J, Abreau S, Wan D, Gonzalez JE, Tardif JC, So DY, Soni K, Tison GH. CathAI: fully automated coronary angiography interpretation and stenosis estimation. NPJ Digit Med 2023; 6:142. [PMID: 37568050 PMCID: PMC10421915 DOI: 10.1038/s41746-023-00880-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
Coronary angiography is the primary procedure for diagnosis and management decisions in coronary artery disease (CAD), but ad-hoc visual assessment of angiograms has high variability. Here we report a fully automated approach to interpret angiographic coronary artery stenosis from standard coronary angiograms. Using 13,843 angiographic studies from 11,972 adult patients at University of California, San Francisco (UCSF), between April 1, 2008 and December 31, 2019, we train neural networks to accomplish four sequential necessary tasks for automatic coronary artery stenosis localization and estimation. Algorithms are internally validated against criterion-standard labels for each task in hold-out test datasets. Algorithms are then externally validated in real-world angiograms from the University of Ottawa Heart Institute (UOHI) and also retrained using quantitative coronary angiography (QCA) data from the Montreal Heart Institute (MHI) core lab. The CathAI system achieves state-of-the-art performance across all tasks on unselected, real-world angiograms. Positive predictive value, sensitivity and F1 score are all ≥90% to identify projection angle and ≥93% for left/right coronary artery angiogram detection. To predict obstructive CAD stenosis (≥70%), CathAI exhibits an AUC of 0.862 (95% CI: 0.843-0.880). In UOHI external validation, CathAI achieves AUC 0.869 (95% CI: 0.830-0.907) to predict obstructive CAD. In the MHI QCA dataset, CathAI achieves an AUC of 0.775 (95%. CI: 0.594-0.955) after retraining. In conclusion, multiple purpose-built neural networks can function in sequence to accomplish automated analysis of real-world angiograms, which could increase standardization and reproducibility in angiographic coronary stenosis assessment.
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Affiliation(s)
- Robert Avram
- Division of Cardiology, Department of Medicine, University of California, San Francisco, Cardiology, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of Cardiology, Department of Medicine, Montreal Heart Institute - Université de Montréal, 5000 Rue Belanger, Montreal, QC, H1T 1C8, Canada
| | - Jeffrey E Olgin
- Division of Cardiology, Department of Medicine, University of California, San Francisco, Cardiology, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Cardiovascular Research Institute, University of California, San Francisco, CA, 94143, USA
| | - Zeeshan Ahmed
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Louis Verreault-Julien
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Alvin Wan
- Cardiovascular Research Institute, University of California, San Francisco, CA, 94143, USA
| | - Joshua Barrios
- Division of Cardiology, Department of Medicine, University of California, San Francisco, Cardiology, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Sean Abreau
- Division of Cardiology, Department of Medicine, University of California, San Francisco, Cardiology, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Derek Wan
- Department of Electrical Engineering and Computer Science, RISE Lab, University of California, Berkeley, Soda Hall, Berkeley, CA, 94720-1770, USA
| | - Joseph E Gonzalez
- Department of Electrical Engineering and Computer Science, RISE Lab, University of California, Berkeley, Soda Hall, Berkeley, CA, 94720-1770, USA
| | - Jean-Claude Tardif
- Division of Cardiology, Department of Medicine, Montreal Heart Institute - Université de Montréal, 5000 Rue Belanger, Montreal, QC, H1T 1C8, Canada
| | - Derek Y So
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Krishan Soni
- Division of Cardiology, Department of Medicine, University of California, San Francisco, Cardiology, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Geoffrey H Tison
- Division of Cardiology, Department of Medicine, University of California, San Francisco, Cardiology, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
- Cardiovascular Research Institute, University of California, San Francisco, CA, 94143, USA.
- Department of Electrical Engineering and Computer Science, RISE Lab, University of California, Berkeley, Soda Hall, Berkeley, CA, 94720-1770, USA.
- Bakar Computational Health Sciences Institute, University of California, San Francisco, 94158, USA.
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Zhang H, Mu L, Hu S, Nallamothu BK, Lansky AJ, Xu B, Bouras G, Cohen DJ, Spertus JA, Masoudi FA, Curtis JP, Gao R, Ge J, Yang Y, Li J, Li X, Zheng X, Li Y, Krumholz HM, Jiang L. Comparison of Physician Visual Assessment With Quantitative Coronary Angiography in Assessment of Stenosis Severity in China. JAMA Intern Med 2018; 178:239-247. [PMID: 29340571 PMCID: PMC5838612 DOI: 10.1001/jamainternmed.2017.7821] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Although physician visual assessment (PVA) of stenosis severity is a standard clinical practice to support decisions for coronary revascularization, there are concerns about its accuracy. OBJECTIVE To compare PVA with quantitative coronary angiography (QCA) as a means of assessing stenosis severity among patients undergoing percutaneous coronary intervention (PCI) in China. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study (2012-2013) of a random subset of 1295 patients from the China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Prospective PCI Study was carried out. The PEACE Prospective PCI study recruited a consecutive sample of patients undergoing PCI at 35 hospitals in 18 provinces of China. The coronary angiograms of this subset of participants were reviewed using QCA by 2 independent core laboratories blinded to PVA readings. MAIN OUTCOMES AND MEASURES Differences between PVA and QCA assessments of stenosis severity for lesions for which PCI was performed and variation of these differences among hospitals and physicians, stratified by the diagnosis of acute myocardial infarction (AMI). RESULTS In patients without AMI, the mean (SD) age was 62 (10) years, and 217 (31.5%) were women; in patients with AMI, the mean (SD) age was 60 (11) years, and 153 (25.2%) were women. The mean (SD) percent diameter stenosis by PVA was 16.0% (11.5%) greater than that by QCA in patients without AMI and 10.2% (12.3%) in those with AMI (P < .001 for both comparisons). In patients without AMI, of 837 lesions with 70% or more stenosis by PVA, 427 (50.6%) were less than 70% by QCA; in patients with AMI, similar patterns were observed to a lesser extent. Among patients without AMI, only 4 (0.47%) lesions were additionally assessed with fractional flow reserve. Among 30 hospitals, the difference between PVA and QCA readings of stenosis severity varied from 7.6% (95% CI, 0.4%-14.7%) to 21.3% (95% CI, 17.1%-24.9%) among non-AMI patients. Across 57 physicians, this difference varied from 6.9% (95% CI, -1.4%-15.3%) to 26.4% (95% CI, 21.5%-31.4%). CONCLUSIONS AND RELEVANCE For coronary lesions treated with PCI in China, PVA reported substantially higher readings of stenosis severity than QCA, with large variation across hospitals and physicians. These findings highlight the need to improve the accuracy of information used to guide treatment decisions in catheterization laboratories.
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Affiliation(s)
- Haibo Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lin Mu
- Yale University School of Medicine, New Haven, Connecticut, United States.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Shuang Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Brahmajee K Nallamothu
- Ann Arbor VA Center for Clinical Management and Research and University of Michigan Health System, Ann Arbor, Michigan
| | | | - Bo Xu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | | | - David J Cohen
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Runlin Gao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yuejin Yang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yetong Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Reliability and Accuracy of Simple Visual Estimation in Assessment of Peripheral Arterial Stenosis. J Vasc Interv Radiol 2015; 26:890-6. [DOI: 10.1016/j.jvir.2015.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/19/2015] [Accepted: 02/19/2015] [Indexed: 11/23/2022] Open
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Nallamothu BK, Spertus JA, Lansky AJ, Cohen DJ, Jones PG, Kureshi F, Dehmer GJ, Drozda JP, Walsh MN, Brush JE, Koenig GC, Waites TF, Gantt DS, Kichura G, Chazal RA, O'Brien PK, Valentine CM, Rumsfeld JS, Reiber JHC, Elmore JG, Krumholz RA, Weaver WD, Krumholz HM. Comparison of clinical interpretation with visual assessment and quantitative coronary angiography in patients undergoing percutaneous coronary intervention in contemporary practice: the Assessing Angiography (A2) project. Circulation 2013; 127:1793-800. [PMID: 23470859 DOI: 10.1161/circulationaha.113.001952] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies conducted decades ago described substantial disagreement and errors in physicians' angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently undertaken. METHODS AND RESULTS We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention at 7 US hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen weighted κ statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (quartiles 1 and 3, 80.0% and 90.0%), with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was 8.2±8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted κ of 0.27 (95% confidence interval, 0.18-0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA, although none were <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50% to <70%), with variation existing across sites. CONCLUSIONS Physicians tended to assess coronary lesions treated with percutaneous coronary intervention as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, whereas approximately one quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.
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Affiliation(s)
- Brahmajee K Nallamothu
- Ann Arbor VA Center for Clinical Management and Research and University of Michigan Health System, Ann Arbor, MI, USA.
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Poulin F, Rinfret S, Gobeil F. Potential shift from coronary bypass surgery to percutaneous coronary intervention for multivessel disease and its economic impact in the drug-eluting stent era. Can J Cardiol 2008; 23:1139-45. [PMID: 18060100 DOI: 10.1016/s0828-282x(07)70885-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Drug-eluting stents (DES) may promote percutaneous coronary intervention (PCI) procedures in patients traditionally referred for coronary artery bypass graft (CABG) surgery and may save money. OBJECTIVES The purpose of the present study was to quantify the potential shift from CABG surgery to multivessel PCI in the DES era and to model the economic consequences. METHODS Based on predefined criteria, the feasibility of PCI was evaluated in patients with multivessel coronary artery disease who underwent CABG surgery before the availability of DES at the Centre Hospitalier de l'Université de Montréal's Notre-Dame Hospital (Montreal, Quebec). Modelling was used to evaluate the potential cost savings using multivessel PCI instead of CABG surgery. Equal one-year outcomes in both groups were assumed, with the exception of a 10% repeat revascularization (RR) rate in the DES group and a 4% RR rate in the CABG group. The impact of those assumptions was evaluated using 1000 Monte Carlo simulations. RESULTS The authors retrospectively evaluated that, of 289 patients who underwent CABG without concomitant valve surgery between January and December 2003, only 22 patients (8%) were good candidates for multivessel DES implantation. The procedures would have involved an average of 3.6 DES per patient. The average cost per revascularization procedure was $14,402 with surgery and $11,220 for multivessel DES implantation (using $2,200 DES), leading to a savings of $3,182 per patient. However, after including RR procedures, PCI would only have been associated with savings of $812 per surgery avoided. Monte Carlo analysis revealed that surgery may be less expensive than PCI in 36% of patients. CONCLUSIONS Most patients who underwent CABG surgery in 2003 were retrospectively judged to be ineligible for multivessel PCI with DES. In the rare eligible patient, multivessel PCI with DES is not expected to produce savings to health care costs in Canada unless the DES purchase cost continues to decrease.
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Affiliation(s)
- Frédéric Poulin
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Gardiner GA, Sullivan KL, Halpern EJ, Parker L, Beck M, Bonn J, Levin DC. Angiographic Assessment of Initial Balloon Angioplasty Results. J Vasc Interv Radiol 2004; 15:1081-7. [PMID: 15466794 DOI: 10.1097/01.rvi.0000137398.73970.d5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To determine the influence of three factors involved in the angiographic assessment of balloon angioplasty-interobserver variability, operator bias, and the definition used to determine success-on the primary (technical) results of angioplasty in the peripheral arteries. MATERIALS AND METHODS Percent stenosis in 107 lesions in lower-extremity arteries was graded by three independent, experienced vascular radiologists ("observers") before and after balloon angioplasty and their estimates were compared with the initial interpretations reported by the physician performing the procedure ("operator") and an automated quantitative computer analysis. Observer variability was measured with use of intraclass correlation coefficients and SD. Differences among the operator, observers, and the computer were analyzed with use of the Wilcoxon signed-rank test and analysis of variance. For each evaluator, the results in this series of lesions were interpreted with three different definitions of success. RESULTS Estimation of residual stenosis varied by an average range of 22.76% with an average SD of 8.99. The intraclass correlation coefficients averaged 0.59 for residual stenosis after angioplasty for the three observers but decreased to 0.36 when the operator was included as the fourth evaluator. There was good to very good agreement among the three independent observers and the computer, but poor correlation with the operator (P </= .001). The primary success rates for this series of lesions varied from a low of 47% to high of 99%, depending solely on which definition of success was used. Significant differences among the operator, the three observers, and the computer were not present when the definition of success was based on less than 50% residual stenosis. CONCLUSIONS Observer variability and bias in the subjective evaluation of peripheral angioplasty can have a significant influence on the reported initial success rates. This effect can be largely eliminated with the use of residual stenosis of less than 50% to define success. Otherwise, meaningful evaluation of angioplasty results will require independent panels of evaluators or computerized measurements.
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Affiliation(s)
- Geoffrey A Gardiner
- Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, Philadelphia, Pennsylvania, USA.
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7
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Ogawa S, Ohkubo T, Fukazawa R, Kamisago M, Kuramochi Y, Uchikoba Y, Ikegami E, Watanabe M, Katsube Y. Estimation of myocardial hemodynamics before and after intervention in children with kawasaki disease. J Am Coll Cardiol 2004; 43:653-61. [PMID: 14975478 DOI: 10.1016/j.jacc.2003.10.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2003] [Revised: 09/12/2003] [Accepted: 10/11/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES We used myocardial fractional flow reserve (FFR(myo)) and coronary flow reserve (CFR) to estimate cut-off values for assessment of the functional severity of coronary stenosis and myocardial ischemia, and we tested the usefulness of coronary blood hemodynamic measurements before and after plain old balloon angioplasty (POBA) and coronary artery bypass graft surgery (CABG). BACKGROUND Fractional flow reserve and CFR are useful for assessing the functional severity of coronary artery stenosis, coronary microvascular dysfunction, and myocardial ischemia during cardiac catheterization in adults. However, there have been no reports on the use of these measurements in children with Kawasaki disease (KD). METHODS The study group included 128 patients with 314 coronary branches. The subjects were classified into three groups: normal coronary group, with 206 branches; abnormal coronary artery without ischemia group, with 58 branches; and ischemia group, with 50 branches. RESULTS In each branch, CFR and FFR(myo) were significantly lower in the ischemia group than in the other groups. Cut-off values for assessing the functional severity of coronary stenosis and CFR were approximately equal to those obtained for adults (CFR: <2.0; FFR(myo): <0.75). We obtained very high sensitivity and specificity for estimating myocardial ischemia using CFR and FFR(myo) (CFR: 94.0% and 98.5%, respectively; FFR(myo): 95.7% and 99.1%, respectively). Both CFR and FFR(myo) were reliable indicators of coronary hemodynamics before and after POBA and CABG. CONCLUSIONS Together, CFR and FFR(myo) provide a useful index for assessing the functional severity of coronary artery stenosis and myocardial ischemia and estimating the effectiveness of POBA and CABG in children with KD, the same as they do for adults.
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Affiliation(s)
- Shunichi Ogawa
- Department of Pediatrics, Nippon Medical School Hospital, Tokyo, Japan.
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Hoffman JIE. Do we have agold standard yet?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2004; 43:662-4. [PMID: 14975479 DOI: 10.1016/j.jacc.2003.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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9
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Banerjee S, Crook AM, Dawson JR, Timmis AD, Hemingway H. Magnitude and consequences of error in coronary angiography interpretation (the ACRE study). Am J Cardiol 2000; 85:309-14. [PMID: 11078298 DOI: 10.1016/s0002-9149(99)00738-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the routine reporting of coronary angiograms, there are no contemporary estimates of the magnitude and consequences of interobserver variability. We therefore measured the agreement beyond chance between (1) the number of narrowed arteries on an angiographic report extracted from case notes and independent assessments by 2 cardiologists, and (2) actual patient management over an 18-month follow-up period and each cardiologist's hypothetical management proposal based on abstracted clinical details. Two hundred nine angiograms were randomly selected from 4,121 patients in a prospective study (Appropriateness of Coronary Revascularisation [ACRE study]). The number of narrowed arteries was defined using Coronary Artery Surgery Study (CASS) criteria. For the number of narrowed arteries, cardiologists A and B agreed with the angiographic report in 126 patients (60%, weighted kappa = 0.64) and 124 patients (59%, weighted kappa = 0.63), respectively. In a subset of 92 patients (44%) there was unanimous agreement on the number of narrowed arteries (both cardiologists agreed with the angiographic report). Comparing actual management (34 percutaneous transluminal coronary angioplasty and 39 coronary artery bypass grafting procedures on follow-up) with each of the cardiologist's management recommendations showed agreement in 150 patients (72%, kappa = 0.46) and 154 patients (74%, kappa = 0.48) for cardiologists A and B, respectively. These agreements on management improved (p = 0.05) for cardiologist B (but not A) when analysis was confined to the subset of 92 patients, showing agreement in 73 patients (79%, kappa = 0.60). Thus, in routine clinical practice, the agreement beyond chance in interpretation of the number of narrowed arteries was good. Disagreements on subsequent patient management arose as a result of, and independent of, errors in angiographic interpretation.
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Affiliation(s)
- S Banerjee
- Royal Hospitals Trust, St. Bartholomew's and the London Chest Hospitals, United Kingdom
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Schreij G, de Haan MW, Oei TK, Koster D, de Leeuw PW. Interpretation of renal angiography by radiologists. J Hypertens 1999; 17:1737-41. [PMID: 10658940 DOI: 10.1097/00004872-199917120-00011] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Different radiologists may show considerable variation in their interpretation of renal angiograms. We therefore wished to establish the reliability of their interpretation. DESIGN Assessment of the intra- and inter-observer agreement of the interpretation of renal angiograms. SETTING Tertiary referral university hospital. PATIENTS Hypertensive patients suspected of renovascular hypertension on clinical grounds or on the basis of renography. INTERVENTIONS Patients were prospectively selected to undergo a renal angiography via the femoral approach. MAIN OUTCOME MEASURES Intra- and inter-observer agreement of the degree and site of stenosis. RESULTS The difference between two estimates of the degree of stenosis ranged from 0 to 65% for the individual readers and from 0 to 75% between two readers. When the site of greatest stenosis was in the origin of the renal artery, the intra-observer agreement kappa ranged from 0.54-0.71, the inter-observer agreement across multiple readers being 0.43. In a post hoc analysis using two different cut-off points of stenosis (50 or 70%), the intra- and inter-observer agreement was better at the 70% cut-off-point. In a subset of patients with stenosis and a renin ratio greater than 1.5, both the intra- and inter-observer agreement were much better than when all angiograms were considered. CONCLUSIONS Assessment of the diagnostic performance of three experienced radiologists in their interpretation of renal artery angiograms indicates that the intra- and inter-observer agreement with respect to their estimates of the degree of stenosis and the site of greatest stenosis are rather poor but their diagnostic performance improves in patients with stenosis and a renin ratio greater than 1.5. There is a need for more objective assessment of renal artery lesions.
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Affiliation(s)
- G Schreij
- Department of Internal Medicine, University Hospital Maastricht, The Netherlands
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11
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Bernstein SJ, Brorsson B, Aberg T, Emanuelsson H, Brook RH, Werkö L. Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group. Heart 1999; 81:470-7. [PMID: 10212163 PMCID: PMC1729044 DOI: 10.1136/hrt.81.5.470] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN Prospective survey and review of medical records. PATIENTS Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have "significant" coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than "optimal" medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.
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Affiliation(s)
- S J Bernstein
- Departments of Medicine and Health, Management and Policy, University of Michigan, Ann Arbor, Veterans Affairs Medical Center, Ann Arbor, MI 48109-0376, USA
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12
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Hamaoka K, Onouchi Z, Kamiya Y, Sakata K. Evaluation of coronary flow velocity dynamics and flow reserve in patients with Kawasaki disease by means of a Doppler guide wire. J Am Coll Cardiol 1998; 31:833-40. [PMID: 9525556 DOI: 10.1016/s0735-1097(98)00019-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To assess the pathophysiologic effects of the coronary sequelae of Kawasaki disease on coronary hemodynamic variables, we regionally evaluated the flow velocity dynamics and flow reserve in coronary vessels with lesions using an intracoronary Doppler flow guide wire. BACKGROUND The pathophysiologic effects of the coronary sequelae of Kawasaki disease on coronary hemodynamic variables have not been completely clarified, and we previously reported some discrepancies between coronary angiographic findings and exercise stress tests in Kawasaki disease. METHODS Doppler phasic coronary flow velocity was determined using an 0.018-in. (0.046-cm) intracoronary Doppler flow guide wire at rest and during the adenosine triphosphate-induced hyperemic response in 95 patients (75 male, 20 female, mean age 9.8+/-6.2 years) with Kawasaki disease. RESULTS In 25 patients with coronary aneurysms in 29 vessels, the average peak velocity and diastolic to systolic velocity ratio were significantly (p < 0.05) decreased in the moderate-sized and large-sized aneurysms. Significantly lower values in coronary flow reserve (CFR) were noted in 3 of 10 vessels with moderate aneurysms and in 4 of 7 vessels with large aneurysms. A significant positive correlation (y = 0.53x + 14.6, r2 = 0.91) was observed between the percent diameter stenosis evaluated by angiography and that calculated from the flow velocity measurement. However, the percent diameter stenosis calculated from the flow velocity measurement was underestimated compared with that determined by angiography in the stenotic lesions of intermediate severity. A reduced CFR was noted in five of seven vessels with intermediate stenosis ranging from 50% to 75%, and also in three vessels with mild stenosis ranging from 30% to 40%. A reduced CFR was also observed in six of the eight angiographically normal vessels associated with the area of reduced perfusion on exercise thallium-201 myocardial scintigraphy. CONCLUSIONS Abnormalities in flow dynamics and a reduction in flow reserve were revealed in coronary aneurysms of intermediate to large size and in stenotic lesions, even of mild to intermediate severity, in patients with Kawasaki disease. Abnormalities in the coronary microcirculation, as well as epicardial lesions, contribute to the pathophysiologic responses in Kawasaki disease.
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Affiliation(s)
- K Hamaoka
- Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine, Japan.
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Dean BL, Lefkowitz DS, Howard VJ, Frey JF, Schwartz S, Chambless LE, Heiserman JE, Feinberg WM, Toole JF. Comparison of centralized versus "site-based" measurement of angiographic stenosis for eligibility in the asymptomatic carotid atherosclerosis study. Invest Radiol 1996; 31:446-50. [PMID: 8818784 DOI: 10.1097/00004424-199607000-00007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
RATIONALE AND OBJECTIVES The authors determine the reliability of centralized versus noncentralized (site-based) measurement of angiographic stenosis of patients enrolled into the multicenter, prospective, Asymptomatic Carotid Atherosclerosis Study by angiographic studies. METHODS Percent agreements and correlations of 244 masked and prospectively interpreted angiograms were calculated for comparison of centralized and noncentralized readers measuring the percent carotid stenosis from the same angiographic studies. Univariate summary statistics for differences in percent stenoses were calculated for these readings. RESULTS Agreement between readings were 88.5% and 91.8% with kappa statistics of 0.77 and 0.73 for > or = 60% and > or = 80% stenosis, respectively, for comparison of 33 centers to the designated central reader. Comparison between the designated central reader and a second central reader derived percent agreements of 85.0% and 86.5% with kappa statistics of 0.69 and 0.41 for > or = 60% and > or = 80% stenoses, respectively, for arteries selected from the original group. Hence, agreement was slightly better between the enrolling centers and the designated central reader than between the two central readers. CONCLUSIONS Both centralized and noncentralized (site-based) methods of angiographic measurement of stenosis are equally reliable for large, prospective, masked, multicenter trials when quality control measures are instituted to ensure uniform application of eligibility criteria.
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Affiliation(s)
- B L Dean
- Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, Arizona, UK
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Kern MJ, Donohue TJ, Aguirre FV, Bach RG, Caracciolo EA, Wolford T, Mechem CJ, Flynn MS, Chaitman B. Clinical outcome of deferring angioplasty in patients with normal translesional pressure-flow velocity measurements. J Am Coll Cardiol 1995; 25:178-87. [PMID: 7798498 DOI: 10.1016/0735-1097(94)00328-n] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The objective of this study was to determine the feasibility, safety and outcome of deferring angioplasty in patients with angiographically intermediate lesions that are found not to limit flow, as determined by direct translesional hemodynamic assessment. BACKGROUND The clinical importance of some coronary stenoses of intermediate angiographic severity frequently requires noninvasive stress testing. Direct translesional pressure and flow measurements may assist in clinical decision making in patients with such stenoses. METHODS Translesional spectral flow velocity (Doppler guide wire) and pressure data were obtained in 88 patients for 100 lesions (26 single-vessel and 74 multivessel coronary artery lesions) with quantitative angiographic coronary narrowings (mean +/- SD diameter narrowing 54 +/- 7% [range 40% to 74%]). Target lesion angioplasty was prospectively deferred on the basis of predetermined normal values, defined as a proximal/distal velocity ratio < 1.7 or a pressure gradient < 25 mm Hg, or both. Patients were followed up for 9 +/- 5 months (range 6 to 30). RESULTS In the deferred angioplasty group, translesional velocity ratios were similar to those of a normal reference group (mean 1.1 +/- 0.32 vs. 1.3 +/- 0.55) and significantly lower than those of a reference cohort of patients who had undergone angioplasty (2.27 +/- 1.2, p < 0.05). The mean translesional pressure gradient in the deferred angioplasty group was also lower than that in the angioplasty group (10 +/- 9 vs. 45 +/- 22 mm Hg, p < 0.001). At follow-up in the deferred angioplasty group, four, six, zero and two patients, respectively, had had subsequent angioplasty, coronary artery bypass graft surgery or myocardial infarction or had died. In one patient, death was related to angioplasty of a nontarget artery lesion, and one patient with multivessel disease had a cardiac arrest due to ventricular fibrillation 12 months after lesion assessment. Among the 10 patients requiring later angioplasty or coronary artery bypass grafting, only six procedures were performed on target arteries. No patient had a complication of translesional flow or pressure measurements. CONCLUSIONS These data demonstrate the safety, feasibility and clinical outcome of deferring angioplasty of coronary artery narrowings associated with normal translesional coronary hemodynamic variables. Given the practice of performing angioplasty without ischemic testing or when testing is inconclusive, translesional hemodynamic data obtained at diagnostic catheterization can identify patients in whom it is safe to postpone angioplasty.
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Affiliation(s)
- M J Kern
- Department of Internal Medicine, Saint Louis University School of Medicine, MO
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