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Aramendía-Vidaurreta V, Solis-Barquero SM, Ezponda A, Vidorreta M, Echeverria-Chasco R, Pascual M, Bastarrika G, Fernández-Seara MA. Assessment of Splenic Switch-Off With Arterial Spin Labeling in Adenosine Perfusion Cardiac MRI. J Magn Reson Imaging 2022. [PMID: 36218288 DOI: 10.1002/jmri.28460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In patients with suspected coronary artery disease (CAD), myocardial perfusion is assessed under rest and pharmacological stress to identify ischemia. Splenic switch-off, defined as the stress to rest splenic perfusion attenuation in response to adenosine, has been proposed as an indicator of stress adequacy. Its occurrence has been previously assessed in first-pass perfusion images, but the use of noncontrast techniques would be highly beneficial. PURPOSE To explore the ability of pseudo-continuous arterial spin labeling (PCASL) to identify splenic switch-off in patients with suspected CAD. STUDY TYPE Prospective. POPULATION Five healthy volunteers (age 24.8 ± 3.8 years) and 32 patients (age 66.4 ± 8.2 years) with suspected CAD. FIELD STRENGTH/SEQUENCE A 1.5-T/PCASL (spin-echo) and first-pass imaging (gradient-echo). ASSESSMENT In healthy subjects, multi-delay PCASL data (500-2000 msec) were acquired to quantify splenic blood flow (SBF) and determine the adequate postlabeling delay (PLD) for single-delay acquisitions (PLD > arterial transit time). In patients, single-delay PCASL (1200 msec) and first-pass perfusion images were acquired under rest and adenosine conditions. PCASL data were used to compute SBF maps and SBF stress-to-rest ratios. Three observers classified patients into "switch-off" and "failed switch-off" groups by visually comparing rest-stress perfusion data acquired with PCASL and first-pass, independently. First-pass categories were used as reference to evaluate the accuracy of quantitative classification. STATISTICAL TESTS Wilcoxon signed-rank, Pearson correlation, kappa, percentage agreement, Generalized Linear Mixed Model, Mann-Whitney, Pearson Chi-squared, receiver operating characteristic, area-under-the-curve (AUC) and confusion matrix. SIGNIFICANCE P value < 0.05. RESULTS A total of 27 patients (84.4%) experienced splenic switch-off according to first-pass categories. Comparison of PCASL-derived SBF maps during stress and rest allowed assessment of splenic switch-off, reflected in a reduction of SBF values during stress. SBF stress-to-rest ratios showed a 97% accuracy (sensitivity = 80%, specificity = 100%, AUC = 85.2%). DATA CONCLUSION This study could demonstrate the feasibility of PCASL to identify splenic switch-off during adenosine perfusion MRI, both by qualitative and quantitative assessments. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: 2.
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Affiliation(s)
- Verónica Aramendía-Vidaurreta
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.,Idisna, Instituto de Investigación Sanitaria de Navarra, Spain
| | - Sergio M Solis-Barquero
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.,Idisna, Instituto de Investigación Sanitaria de Navarra, Spain
| | - Ana Ezponda
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.,Idisna, Instituto de Investigación Sanitaria de Navarra, Spain
| | | | - Rebeca Echeverria-Chasco
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.,Idisna, Instituto de Investigación Sanitaria de Navarra, Spain
| | - Marina Pascual
- Department of Cardiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Gorka Bastarrika
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.,Idisna, Instituto de Investigación Sanitaria de Navarra, Spain
| | - María A Fernández-Seara
- Department of Radiology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain.,Idisna, Instituto de Investigación Sanitaria de Navarra, Spain
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2
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Batra R, Jain V, Sharma P. Adenosine: a partially discovered medicinal agent. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2021; 7:214. [PMID: 34697594 PMCID: PMC8529566 DOI: 10.1186/s43094-021-00353-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/29/2021] [Indexed: 11/18/2022] Open
Abstract
Background A plethora of chemicals exists in human body which can alter physiology in one way or other. Scientists have always been astounded by such abilities of chemicals but as the technology advances, even the chemical which was once expected to be well known changes its status to not really well known. Adenosine is one of the chemicals which is in consonance with the aforementioned statements, although previous articles have covered vast information on role of adenosine in cardiovascular physiology, bacterial pathophysiology and inflammatory diseases. In this review we have discussed adenosine and its congeners as potential promising agents in the treatment of Huntington’s disease, post-traumatic stress disorder, erectile dysfunction, viral infections (SARS-CoV) and anxiety. Main text Adenosine is a unique metabolite of ATP; which serves in signalling as well. It is made up of adenine (a nitrogenous base) and ribo-furanose (pentose) sugar linked by β-N9-glycosidic bond. Adenosine on two successive phosphorylation forms ATP (Adenosine Triphosphate) which is involved in several active processes of cell. It is also one of the building blocks (nucleotides) involved in DNA (Deoxy-ribonucleic Acid) and RNA (Ribonucleic Acid) synthesis. It is also a component of an enzyme called S-adenosyl-L-methionine (SAM) and cyano-cobalamin (vitamin B-12). Adenosine acts by binding to G protein-coupled receptor (GPCR: A1, A2A, A2B and A3) carries out various responses some of which are anti-platelet function, hyperaemic response, bone remodelling, involvement in penile erection and suppression of inflammation. On the other hand, certain microorganisms belonging to genus Candida, Staphylococcus and Bacillus utilize adenosine in order to escape host immune response (phagocytic clearance). These microbes evade host immune response by synthesizing and releasing adenosine (with the help of an enzyme: adenosine synthase-A), at the site of infection. Conclusion With the recent advancement in attribution of adenosine in physiology and pathological states, adenosine and its congeners are being looked forward to bringing a revolution in treatment of inflammation, viral infections, psychiatric and neurodegenerative disorders.
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Affiliation(s)
- Rohit Batra
- Department of Pharmacology, ShriRam College Pharmacy, Banmore, Morena, M.P 476444 India
| | - Vinay Jain
- Department of Pharmacognosy, ShriRam College Pharmacy, Banmore, Morena, M.P 476444 India
| | - Pankaj Sharma
- Department of Pharmaceutics, ShriRam College Pharmacy, Banmore, Morena, M.P 476444 India
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3
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Kotecha T, Monteagudo JM, Martinez-Naharro A, Chacko L, Brown J, Knight D, Knott KD, Hawkins P, Moon JC, Plein S, Xue H, Kellman P, Lockie T, Patel N, Rakhit R, Fontana M. Quantitative cardiovascular magnetic resonance myocardial perfusion mapping to assess hyperaemic response to adenosine stress. Eur Heart J Cardiovasc Imaging 2021; 22:273-281. [PMID: 33188683 DOI: 10.1093/ehjci/jeaa252] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS Assessment of hyperaemia during adenosine stress cardiovascular magnetic resonance (CMR) remains a clinical challenge with lack of a gold-standard non-invasive clinical marker to confirm hyperaemic response. This study aimed to validate maximum stress myocardial blood flow (SMBF) measured using quantitative perfusion mapping for assessment of hyperaemic response and compare this to current clinical markers of adenosine stress. METHODS AND RESULTS Two hundred and eighteen subjects underwent adenosine stress CMR. A derivation cohort (22 volunteers) was used to identify a SMBF threshold value for hyperaemia. This was tested in a validation cohort (37 patients with suspected coronary artery disease) who underwent invasive coronary physiology assessment on the same day as CMR. A clinical cohort (159 patients) was used to compare SMBF to other physiological markers of hyperaemia [splenic switch-off (SSO), heart rate response (HRR), and blood pressure (BP) fall]. A minimum SMBF threshold of 1.43 mL/g/min was derived from volunteer scans. All patients in the coronary physiology cohort demonstrated regional maximum SMBF (SMBFmax) >1.43 mL/g/min and invasive evidence of hyperaemia. Of the clinical cohort, 93% had hyperaemia defined by perfusion mapping compared to 71% using SSO and 81% using HRR. There was no difference in SMBFmax in those with or without SSO (2.58 ± 0.89 vs. 2.54 ± 1.04 mL/g/min, P = 0.84) but those with HRR had significantly higher SMBFmax (2.66 1.86 mL/g/min, P < 0.001). HRR >15 bpm was superior to SSO in predicting adequate increase in SMBF (AUC 0.87 vs. 0.62, P < 0.001). CONCLUSION Adenosine-induced increase in myocardial blood flow is accurate for confirmation of hyperaemia during stress CMR studies and is superior to traditional, clinically used markers of adequate stress such as SSO and BP response.
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Affiliation(s)
- Tushar Kotecha
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, Pond Street, London, UK
| | | | - Ana Martinez-Naharro
- Department of Cardiology, Royal Free Hospital, Pond Street, London, UK.,Division of Medicine, University College London, London, UK
| | - Liza Chacko
- Department of Cardiology, Royal Free Hospital, Pond Street, London, UK.,Division of Medicine, University College London, London, UK
| | - James Brown
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, Pond Street, London, UK
| | - Daniel Knight
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, Pond Street, London, UK
| | - Kristopher D Knott
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiovascular Magnetic Resonance, Barts Heart Centre, London, UK
| | - Philip Hawkins
- Department of Cardiology, Royal Free Hospital, Pond Street, London, UK.,Division of Medicine, University College London, London, UK
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiovascular Magnetic Resonance, Barts Heart Centre, London, UK
| | - Sven Plein
- Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Hui Xue
- Medical Signal and Imaging Processing Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter Kellman
- Medical Signal and Imaging Processing Program, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tim Lockie
- Department of Cardiology, Royal Free Hospital, Pond Street, London, UK
| | - Niket Patel
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, Pond Street, London, UK
| | - Roby Rakhit
- Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, Royal Free Hospital, Pond Street, London, UK
| | - Marianna Fontana
- Department of Cardiology, Royal Free Hospital, Pond Street, London, UK.,Division of Medicine, University College London, London, UK
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Farzaneh-Far A, Wong J. Stressed enough? Hyperaemic thresholds during quantitative cardiovascular magnetic resonance perfusion mapping. Eur Heart J Cardiovasc Imaging 2021; 22:282-284. [PMID: 33338199 DOI: 10.1093/ehjci/jeaa268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Afshin Farzaneh-Far
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, 840 South Wood St. M/C 715, Suite 920 S, Chicago, IL 60612, USA.,Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Joyce Wong
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
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Brown LAE, Saunderson CED, Das A, Craven T, Levelt E, Knott KD, Dall’Armellina E, Xue H, Moon JC, Greenwood JP, Kellman P, Swoboda PP, Plein S. A comparison of standard and high dose adenosine protocols in routine vasodilator stress cardiovascular magnetic resonance: dosage affects hyperaemic myocardial blood flow in patients with severe left ventricular systolic impairment. J Cardiovasc Magn Reson 2021; 23:37. [PMID: 33731141 PMCID: PMC7971951 DOI: 10.1186/s12968-021-00714-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adenosine stress perfusion cardiovascular magnetic resonance (CMR) is commonly used in the assessment of patients with suspected ischaemia. Accepted protocols recommend administration of adenosine at a dose of 140 µg/kg/min increased up to 210 µg/kg/min if required. Conventionally, adequate stress has been assessed using change in heart rate, however, recent studies have suggested that these peripheral measurements may not reflect hyperaemia and can be blunted, in particular, in patients with heart failure. This study looked to compare stress myocardial blood flow (MBF) and haemodynamic response with different dosing regimens of adenosine during stress perfusion CMR in patients and healthy controls. METHODS 20 healthy adult subjects were recruited as controls to compare 3 adenosine perfusion protocols: standard dose (140 µg/kg/min for 4 min), high dose (210 µg/kg/min for 4 min) and long dose (140 µg/kg/min for 8 min). 60 patients with either known or suspected coronary artery disease (CAD) or with heart failure and different degrees of left ventricular (LV) dysfunction underwent adenosine stress with standard and high dose adenosine within the same scan. All studies were carried out on a 3 T CMR scanner. Quantitative global myocardial perfusion and haemodynamic response were compared between doses. RESULTS In healthy controls, no significant difference was seen in stress MBF between the 3 protocols. In patients with known or suspected CAD, and those with heart failure and mild systolic impairment (LV ejection fraction (LVEF) ≥ 40%) no significant difference was seen in stress MBF between standard and high dose adenosine. In those with LVEF < 40%, there was a significantly higher stress MBF following high dose adenosine compared to standard dose (1.33 ± 0.46 vs 1.10 ± 0.47 ml/g/min, p = 0.004). Non-responders to standard dose adenosine (defined by an increase in heart rate (HR) < 10 bpm) had a significantly higher stress HR following high dose (75 ± 12 vs 70 ± 14 bpm, p = 0.034), but showed no significant difference in stress MBF. CONCLUSIONS Increasing adenosine dose from 140 to 210 µg/kg/min leads to increased stress MBF in patients with significantly impaired LV systolic function. Adenosine dose in clinical perfusion assessment may need to be increased in these patients.
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Affiliation(s)
- Louise A. E. Brown
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Christopher E. D. Saunderson
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Arka Das
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Thomas Craven
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Kristopher D. Knott
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD USA
| | - Erica Dall’Armellina
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD USA
| | - James C. Moon
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD USA
| | - John P. Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Peter Kellman
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
- The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, UK
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD USA
| | - Peter P. Swoboda
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
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6
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Rahman H, Scannell CM, Demir OM, Ryan M, McConkey H, Ellis H, Masci PG, Perera D, Chiribiri A. High-Resolution Cardiac Magnetic Resonance Imaging Techniques for the Identification of Coronary Microvascular Dysfunction. JACC Cardiovasc Imaging 2020; 14:978-986. [PMID: 33248969 DOI: 10.1016/j.jcmg.2020.10.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/01/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study assessed the ability to identify coronary microvascular dysfunction (CMD) in patients with angina and nonobstructive coronary artery disease (NOCAD) using high-resolution cardiac magnetic resonance (CMR) and hypothesized that quantitative perfusion techniques would have greater accuracy than visual analysis. BACKGROUND Half of all patients with angina are found to have NOCAD, while the presence of CMD portends greater morbidity and mortality, it now represents a modifiable therapeutic target. Diagnosis currently requires invasive assessment of coronary blood flow during angiography. With greater reliance on computed tomography coronary angiography as a first-line tool to investigate angina, noninvasive tests for diagnosing CMD warrant validation. METHODS Consecutive patients with angina and NOCAD were enrolled. Intracoronary pressure and flow measurements were acquired during rest and vasodilator-mediated hyperemia. CMR (3-T) was performed and analyzed by visual and quantitative techniques, including calculation of myocardial blood flow (MBF) during hyperemia (stress MBF), transmural myocardial perfusion reserve (MPR: MBFHYPEREMIA / MBFREST), and subendocardial MPR (MPRENDO). CMD was defined dichotomously as an invasive coronary flow reserve <2.5, with CMR readers blinded to this classification. RESULTS A total of 75 patients were enrolled (57 ± 10 years of age, 81% women). Among the quantitative perfusion indices, MPRENDO and MPR had the highest accuracy (area under the curve [AUC]: 0.90 and 0.88) with high sensitivity and specificity, respectively, both superior to visual assessment (both p < 0.001). Visual assessment identified CMD with 58% accuracy (41% sensitivity and 83% specificity). Quantitative stress MBF performed similarly to visual analysis (AUC: 0.64 vs. 0.60; p = 0.69). CONCLUSIONS High-resolution CMR has good accuracy at detecting CMD but only when analyzed quantitatively. Although omission of rest imaging and stress-only protocols make for quicker scans, this is at the cost of accuracy compared with integrating rest and stress perfusion. Quantitative perfusion CMR has an increasingly important role in the management of patients frequently encountered with angina and NOCAD.
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Affiliation(s)
- Haseeb Rahman
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Cian M Scannell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Ozan M Demir
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Matthew Ryan
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Hannah McConkey
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Howard Ellis
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Excellence and National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom.
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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7
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Modi BN, Rahman H, Ryan M, Ellis H, Pavlidis A, Redwood S, Clapp B, Chowienczyk P, Perera D. Comparison of fractional flow reserve, instantaneous wave-free ratio and a novel technique for assessing coronary arteries with serial lesions. EUROINTERVENTION 2020; 16:577-583. [PMID: 31543499 DOI: 10.4244/eij-d-19-00635] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Physiological indices such as fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and resting distal coronary to aortic pressure (Pd/Pa) are increasingly used to guide revascularisation. However, reliable assessment of individual stenoses in serial coronary disease remains an unmet need. This study aimed to compare conventional pressure-based indices, a reference Doppler-based resistance index (hyperaemic stenosis resistance [hSR]) and a recently described mathematical correction model to predict the contribution of individual stenoses in serial disease. METHODS AND RESULTS Resting and hyperaemic pressure wire pullbacks were performed in 54 patients with serial disease. For each stenosis, FFR, iFR, and Pd/Pa were measured by the translesional gradient in each index and the predicted FFR (FFRpred) derived mathematically from hyperaemic pullback data. "True" stenosis significance by each index was assessed following PCI of the accompanying stenosis or measurements made in a large disease-free branch. In 27 patients, Doppler average peak flow velocity (APV) was also measured to calculate hSR (hSR=∆P/APV, where ∆P=translesional pressure gradient). FFR underestimated individual stenosis severity, inversely proportional to cumulative FFR (r=0.5, p<0.001). Mean errors for FFR, iFR and Pd/Pa were 33%, 20% and 24%, respectively, and 14% for FFRpred (p<0.001). Stenosis misclassification rates based on FFR 0.80, iFR 0.89 and Pd/Pa 0.91 thresholds were not significantly different (17%, 24% and 20%, respectively) but were higher than FFRpred (11%, p<0.001). Apparent and true hSR correlated strongly (r=0.87, p<0.001, mean error 0.19±0.3), with only 7% of stenoses misclassified. CONCLUSIONS Individual stenosis severity is significantly underestimated in the presence of serial disease, using both hyperaemic and resting pressure-based indices. hSR is less prone to error but challenges in optimising Doppler signals limit clinical utility. A mathematical correction model, using data from hyperaemic pressure wire pullback, produces similar accuracy to hSR and is superior to conventional pressure-based indices.
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Affiliation(s)
- Bhavik N Modi
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, St Thomas' Campus, King's College London, London, United Kingdom
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8
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Ford TJ, Ong P, Sechtem U, Beltrame J, Camici PG, Crea F, Kaski JC, Bairey Merz CN, Pepine CJ, Shimokawa H, Berry C. Assessment of Vascular Dysfunction in Patients Without Obstructive Coronary Artery Disease: Why, How, and When. JACC Cardiovasc Interv 2020; 13:1847-1864. [PMID: 32819476 PMCID: PMC7447977 DOI: 10.1016/j.jcin.2020.05.052] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/23/2020] [Accepted: 05/05/2020] [Indexed: 02/08/2023]
Abstract
Ischemic heart disease secondary to coronary vascular dysfunction causes angina and impairs quality of life and prognosis. About one-half of patients with symptoms and signs of ischemia turn out not to have obstructive coronary artery disease, and coronary vascular dysfunction may be relevant. Adjunctive tests of coronary vasomotion include guidewire-based techniques with adenosine and reactivity testing, typically by intracoronary infusion of acetylcholine. The CorMicA (Coronary Microvascular Angina) trial provided evidence that routine management guided by an interventional diagnostic procedure and stratified therapy improves angina and quality of life in patients with angina but no obstructive coronary artery disease. In this paper, the COVADIS study group provide a comprehensive review of why, how, and when coronary vascular dysfunction should be assessed invasively. They discuss the rationale through a shared understanding of vascular pathophysiology and clinical evidence. They propose a consensus approach to how an interventional diagnostic procedure is performed with focus on practical aspects. Finally, the authors discuss the clinical scenarios in patients with stable and acute coronary syndromes in which measurement of coronary vascular function may be helpful for patient care.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Faculty of Medicine, University of Newcastle, Callaghan, Australia; Department of Cardiology, Gosford Hospital, Central Coast Local Health District, Gosford, Australia
| | - Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - John Beltrame
- Basil Hetzel Institute, Central Adelaide Local Health Network, University of Adelaide, Adelaide, Australia
| | - Paolo G Camici
- Vita Salute University and San Raffaele Hospital, Milan, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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9
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Giusca S, Wolf D, Hofmann N, Hagstotz S, Forschner M, Schueler M, Nunninger P, Kelle S, Korosoglou G. Splenic Switch-Off for Determining the Optimal Dosage for Adenosine Stress Cardiac MR in Terms of Stress Effectiveness and Patient Safety. J Magn Reson Imaging 2020; 52:1732-1742. [PMID: 32557923 DOI: 10.1002/jmri.27248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adenosine stress MRI is well established for the evaluation of known and suspected coronary artery disease. However, a proportion of patients might be "under-stressed" using the standard adenosine dose. PURPOSE To compare three different adenosine dosages for stress MRI in terms of stress adequacy based on splenic switch-off (SSO) and limiting side effects. STUDY TYPE Prospective. POPULATION In all, 100 patients were randomized in group 1 (33 pts), group 2 (34 pts), and group 3 (33 pts), receiving dosages of 140 μg/kg/min, 175 μg/kg/min, or 210 μg/kg/min, respectively. SSO was evaluated visually and quantitatively. SEQUENCE Stress perfusion was performed using a 1.5T scanner in three short axes using a standard single-shot, saturation recovery gradient-echo sequence. ASSESSMENT Three blinded experienced operators evaluated SSO on stress and rest perfusion acquisitions in the three groups. The signal intensity of the spleen and myocardium and the presence of inducible ischemia and late gadolinium enhancement were assessed. STATISTICAL ANALYSIS T-test, analysis of variance (ANOVA), chi-squared test, and Pearson's correlation coefficient. RESULTS SSO was present more frequently in patients receiving 175 μg/kg/min and 210 μg/kg/min (31/33 [94%] and 27/29 [93%], respectively) compared to those receiving the standard dose (19/33 [58%], P < 0.05). A positive stress result was noted in 3/33 (9%) patients receiving 140 μg/kg/min vs. 9/33 (27%) patients receiving 175 μg/kg/min and 10/31 (33%) patients receiving 210 μg/kg/min (P < 0.05 for all, P < 0.05 for group 1 vs. groups 2, 3). The relative decrease of splenic signal intensity at hyperemia vs. baseline was significantly lower in group 1 compared to groups 2 and 3 (-33% vs. -54%, -56%, respectively; P < 0.05). No adverse events during scanning were noted in groups 1 and 2, whereas in group 3 four examinations were stopped due to severe dyspnea (n = 2) and AV-blockage (n = 2). DATA CONCLUSION A dosage of 175 μg/kg/min adenosine results in a higher proportion of SSO, which may be an indirect marker of adequate coronary vasodilatation and simultaneously offers similar safety compared to the standard 140 μg/kg/min dosage. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 2 J. MAGN. RESON. IMAGING 2020;52:1732-1742.
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Affiliation(s)
- Sorin Giusca
- Department of Cardiology Angiology and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - David Wolf
- Department of Cardiology Angiology and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Nina Hofmann
- Department of Cardiology Angiology and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Saskia Hagstotz
- Department of Cardiology Angiology and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | | | - Melanie Schueler
- Department of Cardiology Angiology and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | | | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Charité Campus Virchow Clinic, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Grigorios Korosoglou
- Department of Cardiology Angiology and Pneumology, GRN Hospital Weinheim, Weinheim, Germany
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Knott KD, Augusto JB, Nordin S, Kozor R, Camaioni C, Xue H, Hughes RK, Manisty C, Brown LAE, Kellman P, Ramaswami U, Hughes D, Plein S, Moon JC. Quantitative Myocardial Perfusion in Fabry Disease. Circ Cardiovasc Imaging 2019; 12:e008872. [PMID: 31269811 DOI: 10.1161/circimaging.119.008872] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fabry disease (FD) is an X-linked lysosomal storage disease resulting in tissue accumulation of sphingolipids. Key myocardial processes that lead to adverse outcomes in FD include storage, hypertrophy, inflammation, and fibrosis. These are quantifiable by multiparametric cardiovascular magnetic resonance. Recent developments in cardiovascular magnetic resonance perfusion mapping allow rapid in-line perfusion quantification permitting broader clinical application, including the assessment of microvascular dysfunction. We hypothesized that microvascular dysfunction in FD would be associated with storage, fibrosis, and edema. METHODS A prospective, observational study of 44 FD patients (49 years, 43% male, 24 [55%] with left ventricular hypertrophy [LVH]) and 27 healthy controls with multiparametric cardiovascular magnetic resonance including vasodilator stress perfusion mapping. Myocardial blood flow (MBF) was measured and its associations with other processes investigated. RESULTS Compared with LVH- FD, LVH+ FD had higher left ventricular ejection fraction (73% versus 68%), more late gadolinium enhancement (85% versus 15%), and a lower stress MBF (1.76 versus 2.36 mL/g per minute). The reduction in stress MBF was more pronounced in the subendocardium than subepicardium. LVH- FD had lower stress MBF than controls (2.36 versus 3.00 mL/g per minute; P=0.002). Across all FD, late gadolinium enhancement and low native T1 were independently associated with reduced stress MBF. On a per-segment basis, stress MBF was independently associated with wall thickness, T2, extracellular volume fraction, and late gadolinium enhancement. CONCLUSIONS FD patients have reduced perfusion, particularly in the subendocardium with greater reductions with LVH, storage, edema, and scar. Perfusion is reduced even without LVH suggesting it is an early disease marker.
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Affiliation(s)
- Kristopher D Knott
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., J.B.A., S.N., R.K.H., C.M., J.C.M.).,Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
| | - Joao B Augusto
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., J.B.A., S.N., R.K.H., C.M., J.C.M.).,Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
| | - Sabrina Nordin
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., J.B.A., S.N., R.K.H., C.M., J.C.M.).,Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
| | - Rebecca Kozor
- Sydney Medical School, University of Sydney, Australia (R.K.)
| | - Claudia Camaioni
- Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
| | - Hui Xue
- Medical Signal and Image Processing, National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD (H.X., P.K.)
| | - Rebecca K Hughes
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., J.B.A., S.N., R.K.H., C.M., J.C.M.).,Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., J.B.A., S.N., R.K.H., C.M., J.C.M.).,Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
| | - Louise A E Brown
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, United Kingdom (L.A.E.B., S.P.)
| | - Peter Kellman
- Medical Signal and Image Processing, National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD (H.X., P.K.)
| | - Uma Ramaswami
- Lysosomal Storage Disorder Unit, Royal Free Hospital, London, United Kingdom (U.R., D.H.)
| | - Derralyn Hughes
- Lysosomal Storage Disorder Unit, Royal Free Hospital, London, United Kingdom (U.R., D.H.)
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Clarendon Way, United Kingdom (L.A.E.B., S.P.)
| | - James C Moon
- Institute of Cardiovascular Science, University College London, United Kingdom (K.D.K., J.B.A., S.N., R.K.H., C.M., J.C.M.).,Advanced Cardiac Imaging, Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit and The Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (K.D.K., J.B.A., S.N., C.C., R.K.H., C.M., J.C.M.)
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