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Choustoulakis E, Cosyns B, Sonck J, Roosens B, Pien K, Argacha JF, Lochy S, Hubloue I, de Mey J, Putman K. FFRct use for acute chest pain triage in the emergency department: a cost-effectiveness analysis. Acta Cardiol 2024; 79:167-178. [PMID: 38051089 DOI: 10.1080/00015385.2023.2285552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/14/2023] [Indexed: 12/07/2023]
Abstract
AIMS To model and assess the cost-effectiveness of CT-based fractional flow reserve (FFRct) for a population of low to intermediate risk patients for coronary artery disease (CAD) presenting to the emergency department (ED) with acute chest pain. METHODS AND RESULTS Using a decision tree model with a 1 year time horizon and from a health care perspective, two diagnostic pathways using FFRct are compared to current clinical routine combining coronary computed tomography angiography (CCTA) with an exercise test. Model data are drawn from the literature and nationally reported data. Outcomes are assessed as the number of avoided invasive coronary angiographies (ICAs) showing no obstructive CAD and quality of life (QoL) in a theoretical cohort of 1000 patients. Sensitivity analyses are performed to test the robustness of the results. Determining FFRct when CCTA is inconclusive is a cost-effective and dominant strategy with a potential saving of 198€/patient, 154 avoided unnecessary ICA showing no obstructive CAD (uICA)/1000 patients and an average improvement in QoL of 0.008 QALY/patient. With an additional 574€/patient, 8 avoided uICA/1000 patients and an improvement in QoL of 0.001 QALY/patient, a strategy where FFRct is always performed is cost-effective only when considering high cost-effectiveness thresholds. CONCLUSIONS For patients presenting to the ED with acute chest pain and a low to intermediate pre-test probability of CAD, a diagnostic strategy where FFRct is determined after an inconclusive CCTA is cost-effective. Clinical trials investigating both sensitivity and specificity of FFRct, as well as QoL associated with the use of this technology in this setting are warranted.
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Affiliation(s)
- Eleftherios Choustoulakis
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Bram Roosens
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Karen Pien
- Department of Medical Registration, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jean-François Argacha
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Stijn Lochy
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, Emergency and Disaster Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Johan de Mey
- Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Koen Putman
- Department of Public Health, Faculty of Medicine and Pharmacy, Interuniversity Centre of Health Economic Research, Vrije Universiteit Brussel, Brussels, Belgium
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2
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Rigney GH, King AH, Chung J, Ghoshal S, Jain A, Shi Z, Razak S, Hirsch JA, Lev MH, Buch K, Succi MD. Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department. Intern Emerg Med 2024:10.1007/s11739-024-03569-9. [PMID: 38512433 DOI: 10.1007/s11739-024-03569-9] [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: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024]
Abstract
Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care. The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.
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Affiliation(s)
- Grant H Rigney
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Alexander H King
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Janice Chung
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Soham Ghoshal
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Aditya Jain
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Zhuo Shi
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Shahaan Razak
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Joshua A Hirsch
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Michael H Lev
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Karen Buch
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Marc D Succi
- Harvard Medical School, Boston, USA.
- Department of Radiology, Massachusetts General Hospital, Boston, USA.
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA.
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3
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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4
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 434] [Impact Index Per Article: 434.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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5
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Qasum M, Massalha S, Marcusohn E, Elias A, Darawshi S, Zukermann R. Coronary computed tomography angiography in the evaluation of acute chest pain in patients with elevated high sensitive cardiac troponin I (hs-cTn) level. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100276. [PMID: 38511099 PMCID: PMC10945961 DOI: 10.1016/j.ahjo.2023.100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/22/2024]
Abstract
Aims CCTA is a well-established and safe imaging modality for the diagnosis of CAD and is gate keeping for invasive coronary angiography (ICA). We aimed to examine CCTA performance in patients presenting with ACP and dynamic hs-cTn elevation compatible with MI but not exceeding 7 folds of the URL. We also examined the performance of GRACE and PTP consortium scores in this population of patients.
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Affiliation(s)
- Majd Qasum
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Samia Massalha
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Erez Marcusohn
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Adi Elias
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Said Darawshi
- Department of Medicine D, Ruth & Bruce Rappaport Faculty of Medicine, Rambam Health Care Campus, Technion-IIT, Haifa, Israel
| | - Robert Zukermann
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
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Maroules CD, Rybicki FJ, Ghoshhajra BB, Batlle JC, Branch K, Chinnaiyan K, Hamilton-Craig C, Hoffmann U, Litt H, Meyersohn N, Shaw LJ, Villines TC, Cury RC. 2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: An expert consensus document of the Society of cardiovascular computed tomography (SCCT): Endorsed by the American College of Radiology (ACR) and North American Society for cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2023; 17:146-163. [PMID: 36253281 DOI: 10.1016/j.jcct.2022.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
Coronary computed tomography angiography (CTA) improves the quality of care for patients presenting with acute chest pain (ACP) to the emergency department (ED), particularly in patients with low to intermediate likelihood of acute coronary syndrome (ACS). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of coronary CTA to ensure appropriate, safe, and efficient use of this modality. Because of the increasing use of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients in the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.
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Affiliation(s)
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Juan C Batlle
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA
| | - Kelley Branch
- Department of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Harold Litt
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nandini Meyersohn
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Todd C Villines
- Department of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ricardo C Cury
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA
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7
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Ippolito D, Talei Franzesi C, Cangiotti C, Riva L, De Vito A, Gandola D, Maino C, Marra P, Muscogiuri G, Sironi S. Inter-observer agreement and image quality of model-based algorithm applied to the Coronary Artery Disease-Reporting and Data System score. Insights Imaging 2022; 13:176. [DOI: 10.1186/s13244-022-01286-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/24/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Purpose
To evaluate the inter-observer agreement of the CAD-RADS reporting system and compare image quality between model-based iterative reconstruction algorithm (MBIR) and standard iterative reconstruction algorithm (IR) of low-dose cardiac computed tomography angiography (CCTA).
Methods
One-hundred-sixty patients undergone a 256-slice MDCT scanner using low-dose CCTA combined with prospective ECG-gated techniques were enrolled. CCTA protocols were reconstructed with both MBIR and IR. Each study was evaluated by two readers using the CAD-RADS lexicon. Vessels enhancement, image noise, signal-to-noise (SNR), and contrast-to-noise (CNR) were computed in the axial native images, and inter-observer agreement was assessed. Radiation dose exposure as dose–length product (DLP) and effective dose were finally reported.
Results
The reliability analysis between the two readers was almost perfect for all CAD-RADS standard categories. Moreover, a significantly higher value of subjective qualitative analysis, SNR, and CNR in MBIR images compared to IR were found, due to a lower noise level (all p < 0.05). The mean DLP measured was 63.9 mGy*cm, and the mean effective dose was 0.9 mSv.
Conclusion
Inter-observer agreement of CAD-RADS was excellent confirming the importance, the feasibility, and the reproducibility of the CAD-RADS scoring system for CCTA. Moreover, lower noise and higher image quality with MBIR compared to IR were found.
Implications for practice
MBIR, by reducing noise and improving image quality, can help a better assessment of CAD-RADS, in comparison with standard IR algorithm.
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8
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Mehta P, McDonald S, Hirani R, Good D, Diercks D. Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis. Acad Emerg Med 2022; 29:748-764. [PMID: 34741781 DOI: 10.1111/acem.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low- to intermediate-risk patients. METHODS Initially, 952 articles were identified for screening, 81 met criteria for full-text review, and once risk of bias was assessed, 33 articles were included in this meta-analysis. We utilized a random-effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low- to intermediate-risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q-test and I2 statistic. RESULTS Twenty-one studies evaluated follow-up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within-group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). CONCLUSIONS Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.
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Affiliation(s)
- Prayag Mehta
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raiz Hirani
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Good
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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9
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Kearney A, Linden K, Savage P, Menown IBA. Advances in Clinical Cardiology 2020: A Summary of Key Clinical Trials. Adv Ther 2021; 38:2170-2200. [PMID: 33844133 PMCID: PMC8040014 DOI: 10.1007/s12325-021-01711-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/12/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Despite the challenge of a global pandemic, 2020 has been an invaluable year in cardiology research with numerous important clinical trials published or presented virtually at major international meetings. This article aims to summarise these trials and place them in clinical context. METHODS The authors reviewed clinical trials presented at major cardiology conferences during 2020 including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics and the American Heart Association. Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. RESULTS A total of 87 key cardiology clinical trials were identified for inclusion. New interventional and structural cardiology data included trials evaluating bifurcation percutaneous coronary intervention (PCI) techniques, intravascular ultrasound (IVUS)-guided PCI, instantaneous wave-free (iFR) physiological assessment, new generation stents (DynamX bioadaptor), transcatheter aortic valve implantation (TAVI) in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included new data with proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab), omega-3 supplements, evinacumab and colchicine in the setting of chronic coronary artery disease. Antiplatelet data included trials evaluating both the optimal length of course following PCI and combination of antiplatelet agents and regimes including combination antithrombotic therapies for patients with atrial fibrillation (AF). Heart failure data included the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors (sotagliflozin, empagliflozin and dapagliflozin) and mavacamten in hypertrophic cardiomyopathy. Electrophysiology trials included early rhythm control in AF and screening for AF. CONCLUSION This article presents a summary of key clinical cardiology trials during the past year and should be of relevance to both clinicians and cardiology researchers.
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Affiliation(s)
- Aileen Kearney
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Katie Linden
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Patrick Savage
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Ian B A Menown
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK.
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11
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2598] [Impact Index Per Article: 866.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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12
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Grandhi GR, Batlle JC, Maroules CD, Janowitz W, Peña CS, Ziffer JA, Macedo R, Nasir K, Cury RC. Combined stress myocardial CT perfusion and coronary CT angiography as a feasible strategy among patients presenting with acute chest pain to the emergency department. J Cardiovasc Comput Tomogr 2020; 15:129-136. [PMID: 32807703 DOI: 10.1016/j.jcct.2020.06.195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/30/2020] [Accepted: 06/13/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND A combined approach of myocardial CT perfusion (CTP) with coronary CT angiography (CTA) was shown to have better diagnostic accuracy than coronary CTA alone. However, data on cost benefits and length of stay when compared to other perfusion imaging modalities has not been evaluated. Therefore, we aim to perform a feasibility study to assess direct costs and length of stay of a combined stress CTP/CTA and use SPECT myocardial perfusion imaging (SPECT-MPI) as a benchmark, among chest pain patients at intermediate-risk for acute coronary syndrome (ACS) presenting to the emergency department (ED). METHODS This is a prospective two-arm clinical trial (NCT02538861) with 43 patients enrolled in stress CTP/CTA arm (General Electric Revolution CT) and 102 in SPECT-MPI arm. Mean age of the study population was 65 ± 12 years; 56% were men. We used multivariable linear regression analysis to compare length of stay and direct costs between the two modalities. RESULTS Overall, 9 out of the 43 patients (21%) with CTP/CTA testing had an abnormal test. Of these 9 patients, 7 patients underwent invasive coronary angiography and 6 patients were found to have obstructive coronary artery disease. Normal CTP/CTA test was found in 34 patients (79%), who were discharged home and all patients were free of major adverse cardiac events at 30 days. The mean length of stay was significantly shorter by 28% (mean difference: 14.7 h; 95% CI: 0.7, 21) among stress CTP/CTA (20 h [IQR: 16, 37]) compared to SPECT-MPI (30 h [IQR: 19, 44.5]). Mean direct costs were significantly lower by 44% (mean difference: $1535; 95% CI: 987, 2082) among stress CTA/CTP ($1750 [IQR: 1474, 2114] compared to SPECT-MPI ($2837 [IQR: 2491, 3554]). CONCLUSION Combined stress CTP/CTA is a feasible strategy for evaluation of chest pain patients presenting to ED at intermediate-risk for ACS and has the potential to lead to shorter length of stay and lower direct costs.
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Affiliation(s)
- Gowtham R Grandhi
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Juan C Batlle
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | | | - Warren Janowitz
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Constantino S Peña
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jack A Ziffer
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Robson Macedo
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention & Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, TX, USA; Center for Outcomes Research, Houston Methodist, Houston, TX, USA
| | - Ricardo C Cury
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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Meier D, Skalidis I, De Bruyne B, Qanadli SD, Rotzinger D, Eeckhout E, Collet C, Muller O, Fournier S. Ability of FFR-CT to detect the absence of hemodynamically significant lesions in patients with high-risk NSTE-ACS admitted in the emergency department with chest pain, study design and rationale. IJC HEART & VASCULATURE 2020; 27:100496. [PMID: 32181323 PMCID: PMC7063126 DOI: 10.1016/j.ijcha.2020.100496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/27/2020] [Indexed: 11/02/2022]
Abstract
Background In the era of High-sensitive troponin (hs-Tn), up to 50% of patients with a mild increase of hs-Tn will finally have a normal invasive coronary angiogram. Fractional Flow Reserve (FFR) derived from coronary computed tomographic angiography (FFR-CT) has never been used as a non-invasive tool for the diagnosis of coronary artery disease in patients with high-risk acute coronary syndrome without ST segment elevation (NSTE-ACS). Aims The study aims to determine the role of coronary CT angiography and FFR-CT in the setting of high-risk NSTE-ACS. Methodology We will conduct a prospective trial, enrolling 250 patients admitted with high-risk NSTE-ACS who will rapidly undergo a coronary CT angiography and then a coronary angiography with FFR measurements. Results of coronary CT, FFR-CT and coronary angiography (± FFR) will be compared. Potential significance In conclusion, non-invasive identification of patients with high-risk NSTE-ACS who could avoid coronary angiography would reduce procedure related risks and medical costs.
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Key Words
- ACS, Acute coronary syndrome
- AE, Adverse Event
- Acute coronary syndrome
- CMRI, Cardiac Magnetic resonance imaging
- CT, Computed tomography
- Coronary computed tomography
- ECG, Electrocardiogram
- ED, Emergency department
- FFR, Fractional Flow Reserve
- FFR-CT
- FFR-CT, FFR derived from coronary CT
- Fractional Flow Reserve
- Hs-Tn, High-sensitive troponins
- MACE, Major adverse cardiac events
- MI, Myocardial infraction
- NSTE-ACS, Acute coronary syndromes without ST-segment elevation
- NSTEMI, Non-ST-elevation myocardial infarction
- PCI, Percutaneous Coronary Intervention
- STEMI, ST-elevation myocardial infarction
- URL, Upper Range Limit
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Affiliation(s)
- David Meier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ioannis Skalidis
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Bernard De Bruyne
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Cardiovascular Center Aalst, Aalst, Belgium
| | - Salah Dine Qanadli
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - David Rotzinger
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Italy
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Abordaje invasivo en el síndrome coronario agudo sin elevación del ST. ¿Un enfoque be quick or be dead? Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2019.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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15
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Sanmartín Fernández M, Abellás Sequeiros M. Invasive management in acute non-ST-segment elevation coronary syndromes: be quick or be dead? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:8-10. [PMID: 31699641 DOI: 10.1016/j.rec.2019.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/11/2019] [Indexed: 06/10/2023]
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16
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Lin FY, Villines TC, Narula J, Shaw LJ. What is the clinical role of non-invasive atherosclerosis imaging? J Cardiovasc Comput Tomogr 2019; 13:261-266. [DOI: 10.1016/j.jcct.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 12/25/2022]
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17
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Chinnaiyan KM, Safian RD, Gallagher ML, George J, Dixon SR, Bilolikar AN, Abbas AE, Shoukfeh M, Brodsky M, Stewart J, Cami E, Forst D, Timmis S, Crile J, Raff GL. Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department. JACC Cardiovasc Imaging 2019; 13:452-461. [PMID: 31326487 DOI: 10.1016/j.jcmg.2019.05.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFRCT) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program. BACKGROUND FFRCT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied. METHODS ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFRCT were studied. FFRCT ≤0.80 was considered positive for hemodynamically significant stenosis. RESULTS Among 555 patients, 297 underwent coronary CTA and FFRCT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFRCT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFRCT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFRCT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFRCT when revascularization was deferred. Negative FFRCT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFRCT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFRCT groups ($8,582 vs. $8,048; p = 0.550). CONCLUSIONS In ACP, FFRCT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFRCT, which is associated with higher nonobstructive disease on invasive angiography.
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Affiliation(s)
| | - Robert D Safian
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | | | - Julie George
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Abhay N Bilolikar
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Amr E Abbas
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Mazen Shoukfeh
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Marc Brodsky
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - James Stewart
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Elvis Cami
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - David Forst
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Steven Timmis
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Jason Crile
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Gilbert L Raff
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
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Martellini A, di Mario C. High-sensitivity troponin allows accurate rapid diagnosis and discharge but it is not a substitute for a comprehensive patient evaluation. Intern Emerg Med 2019; 14:341-343. [PMID: 30600524 DOI: 10.1007/s11739-018-2008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Antonio Martellini
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy.
| | - Carlo di Mario
- Structural Interventional Cardiology, University Hospital Careggi, Florence, Italy
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Látal J, Špaček M, Přeček J, Tüdös Z, Hutyra M, Tichý T, Táborský M. Giant-cell myocarditis - A case report and a brief review. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Acute chest pain is a leading cause of Emergency Department visits. Computed tomography angiography plays a vital diagnostic role in such cases, but there are several common challenges associated with the imaging of acute chest pain, which, if unrecognized, can lead to an inconclusive or incorrect diagnosis. These imaging challenges fall broadly into 3 categories: (1) image acquisition, (2) image interpretation (including physiological and pathologic mimics), and (3) result communication. The aims of this review are to describe and illustrate the most common challenges in the imaging of acute chest pain and to provide solutions that will facilitate accurate diagnosis of the causes of acute chest pain in the emergency setting.
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21
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Wächter C, Markus B, Schieffer B. [Cardiac causes of chest pain]. Internist (Berl) 2017; 58:8-21. [PMID: 27981367 DOI: 10.1007/s00108-016-0165-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Because of the life-threatening character and a high prevalence in emergency rooms, cardiac causes are important differential diagnoses of acute chest pain with the need for rapid clarification. In this context the working diagnosis "acute coronary syndrome" (ACS) plays a major role. In a synopsis of the clinical presentation, medical history, electrocardiogram and analysis of cardiac biomarkers, ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris can be specified as entities of ACS. The treatment of ACS consists of an immediate anti-ischemic therapy, anti-thrombotic therapy and invasive coronary diagnostics with subsequent interventional or operative revascularization therapy. The timing of invasive management is essentially determined by the individual patient risk, with the exception of STEMI where interventional revascularization must be undertaken within 120 min of diagnosis. In this context the GRACE 2.0 and TIMI risk score have become established as reliable tools. Another rare but fatal cause of acute chest pain is aortic dissection. An abrupt onset of tearing and sharp chest pains, deficits in pulse as well as the presence of high-risk factors, such as advanced age, arterial hypertension, atherosclerosis, known collagenosis and previous aortic or coronary artery procedures are highly indicative for aortic dissection and additional diagnostic imaging and the highly sensitive D‑dimer should be undertaken. Additionally, inflammatory diseases, such as pericarditis and myocarditis can be associated with chest pains and mimic the character of ACS and should also be considered in the differential diagnostics.
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Affiliation(s)
- C Wächter
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - B Markus
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - B Schieffer
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland.
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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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23
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Zuin G, Parato VM, Groff P, Gulizia MM, Di Lenarda A, Cassin M, Cibinel GA, Del Pinto M, Di Tano G, Nardi F, Rossini R, Ruggieri MP, Ruggiero E, Scotto di Uccio F, Valente S. ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain. Eur Heart J Suppl 2017; 19:D212-D228. [PMID: 28751843 PMCID: PMC5520764 DOI: 10.1093/eurheartj/sux025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.
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Affiliation(s)
- Guerrino Zuin
- Cardiology Unit, Ospedale dell’Angelo, Mestre, Via Paccagnella, 11 30174 VE, Italy
| | - Vito Maurizio Parato
- Cardiology Rehabilitation, Ospedale Madonna del Soccorso, Cardiology Unit, ASUR Marche/AV5—Madonna del Soccorso Hospital, 4-7, via Luciano Manara, 63074, San Benedetto del Tronto (Ascoli Piceno), Italy
| | - Paolo Groff
- Emergency Department, Ospedale Madonna del Soccorso, San Benedetto del Tronto (Ascoli Piceno), Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Matteo Cassin
- Cardiology Department, A.O. Santa Maria degli Angeli, Pordenone, Italy
| | | | | | | | - Federico Nardi
- Cardiology Department, Ospedale Castelli, Verbania, Italy
| | - Roberta Rossini
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Pia Ruggieri
- Emergency-Admission Department, A.O. San Giovanni-Addolorata, Rome, Italy
| | | | | | - Serafina Valente
- Intensive Integrated Cardiology Department, AOU Careggi, Florence, Italy
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André F, Buss SJ, Friedrich MG. The role of MRI and CT for diagnosis and work-up in suspected ACS. Diagnosis (Berl) 2016. [DOI: 10.1515/dx-2016-0029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AbstractThis article describes the role of cardiovascular magnetic resonance (CMR) and cardiac computed tomography (CCT) in the diagnostic work-up of patients with suspected acute coronary syndrome (ACS). Recent studies on the principles, diagnostic targets, clinical utility, accuracy, prognostic relevance and implications for clinical decision-making are discussed and current state-of-the-art and novel approaches are presented. The authors recognize that in ACS, time is of the essence and therefore put a special emphasis on the feasibility of tomographic cardiac imaging in realistic clinical settings.
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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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26
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Triple rule-out computed tomography for risk stratification of patients with acute chest pain. J Cardiovasc Comput Tomogr 2016; 10:291-300. [PMID: 27375202 DOI: 10.1016/j.jcct.2016.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 06/07/2016] [Indexed: 12/22/2022]
Abstract
AIMS Clinical evidence supporting triple rule-out computed tomography (TRO-CT) for rapid screening of cardiovascular disease is limited. We investigated the clinical value of TRO-CT in patients with acute chest pain. METHODS We retrospectively enrolled 1024 patients who visited the emergency department (ED) with acute chest pain and underwent TRO-CT using a 128-slice CT system. TRO-CT was classified as "positive" if it revealed clinically significant cardiovascular disease including obstructive coronary artery disease, pulmonary thromboembolism, or acute aortic syndrome. The clinical endpoint was occurrence of a major adverse cardiovascular event (MACE) within 30 days, defined by a composite of all cause death, myocardial infarction, revascularization, major cardiovascular surgery, or thrombolytic therapy. Clinical risk scores for acute chest pain including TIMI, GRACE, Diamond-Forrester, and HEART were determined and compared to the TRO-CT findings. RESULTS TRO-CT revealed clinically significant cardiovascular disease in 239 patients (23.3%). MACE occurred in 119 patients (49.8%) with positive TRO-CT and in 7 patients (0.9%) with negative TRO-CT (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of TRO-CT was 95%, 88%, 54%, and 99%, respectively. TRO-CT was a better discriminator between patients with vs. without events as compared to clinical risk scores (c-statistics = 0.91 versus 0.64 to 0.71; integrated discrimination improvement = 0.31 to 0.37; p < 0.001 for all comparisons). Patients with a negative TRO-CT showed shorter ED stay times and admission rates compared to patients with positive TRO-CT, irrespective of clinical risk scores (p < 0.001 for all comparisons). CONCLUSION Triple rule-out CT has high predictive performance for 30-day MACE and permits rapid triage and low admission rates irrespective of clinical risk scores.
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Park JH, Kim YK, Kim B, Kim J, Kwon H, Kim K, Choi SI, Chun EJ. Diagnostic performance of smartphone reading of the coronary CT angiography in patients with acute chest pain at ED. Am J Emerg Med 2016; 34:1794-8. [PMID: 27396538 DOI: 10.1016/j.ajem.2016.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/20/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The aims of this study were to simulate mobile consultation for the coronary computed tomography angiography (CCTA) at the emergency department (ED) and to measure the diagnostic performance of the mobile reading. MATERIALS AND METHODS A total of 107 patients with acute chest pain who underwent CCTA and coronary angiography (CAG) were included. The CCTA images were reviewed by a cardiac radiologist using a smartphone. The degree of stenosis at each coronary segment was scored with 4-point scale (score 1, <50%; score 2, 51%-70%; score 3, 71%-90%; score 4, >90%). The degree of stenosis at each coronary segments were also scored with preliminary CCTA report by on-call residents, final CCTA reports by in-house attending cardiac radiologists, and CAG. Interobserver agreement was measured using κ statistics. The areas under the receiver operating characteristic curves (AUCs) for diagnosing segments with obstructive stenosis were compared between each reader and CAG. RESULTS The smartphone reader's reading was more similar to the CAG results and in-house radiologists' reports than reading of on-call residents. The diagnostic performance of smartphone reading for detection of obstructive stenosis was significantly greater than that of on-call residents (AUC, 0.89 vs 0.75; P<.001) and did not significantly differ from that of the in-house radiologists (AUC, 0.89 vs 0.90; P=.05). CONCLUSION Smartphone reading by the cardiac radiologist was superior to the on-call residents' reading. Further study with real-time mobile consultation needs to be investigated to evaluate whether improvement in diagnostic competency can make a difference in the outcome of patients.
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Affiliation(s)
- Jung Hyun Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Yeo Koon Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea.
| | - Bohyoung Kim
- Division of Biomedical Engineering, Hankuk University of Foreign Studies
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Sang Il Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea
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Yun J, Kim YK, Chun EJ, Shin YG, Lee J, Kim B. Stenosis map for volume visualization of constricted tubular structures: Application to coronary artery stenosis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2016; 124:76-90. [PMID: 26608866 DOI: 10.1016/j.cmpb.2015.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 10/08/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Abstract
Although direct volume rendering (DVR) has become a commodity, effective rendering of interesting features is still a challenge. In one of active DVR application fields, the medicine, radiologists have used DVR for the diagnosis of lesions or diseases that should be visualized distinguishably from other surrounding anatomical structures. One of most frequent and important radiologic tasks is the detection of lesions, usually constrictions, in complex tubular structures. In this paper, we propose a 3D spatial field for the effective visualization of constricted tubular structures, called as a stenosis map which stores the degree of constriction at each voxel. Constrictions within tubular structures are quantified by using newly proposed measures (i.e. line similarity measure and constriction measure) based on the localized structure analysis, and classified with a proposed transfer function mapping the degree of constriction to color and opacity. We show the application results of our method to the visualization of coronary artery stenoses. We present performance evaluations using twenty eight clinical datasets, demonstrating high accuracy and efficacy of our proposed method. The ability of our method to saliently visualize the constrictions within tubular structures and interactively adjust the visual appearance of the constrictions proves to deliver a substantial aid in radiologic practice.
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Affiliation(s)
- Jihye Yun
- School of Computer Science and Engineering, Seoul National University, Gwanak-ro, Gwanak-gu, Seoul 151-742, South Korea.
| | - Yeo Koon Kim
- Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea.
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea.
| | - Yeong-Gil Shin
- School of Computer Science and Engineering, Seoul National University, Gwanak-ro, Gwanak-gu, Seoul 151-742, South Korea.
| | - Jeongjin Lee
- School of Computer Science and Engineering, Soongsil University, 369 Sangdo-Ro, Dongjak-Gu, Seoul 156-743, South Korea.
| | - Bohyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea.
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Monsieurs K, Nolan J, Bossaert L, Greif R, Maconochie I, Nikolaou N, Perkins G, Soar J, Truhlář A, Wyllie J, Zideman D. Kurzdarstellung. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Nikolaou N, Arntz H, Bellou A, Beygui F, Bossaert L, Cariou A. Das initiale Management des akuten Koronarsyndroms. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, Perkins GD, Soar J, Truhlář A, Wyllie J, Zideman DA, Alfonzo A, Arntz HR, Askitopoulou H, Bellou A, Beygui F, Biarent D, Bingham R, Bierens JJ, Böttiger BW, Bossaert LL, Brattebø G, Brugger H, Bruinenberg J, Cariou A, Carli P, Cassan P, Castrén M, Chalkias AF, Conaghan P, Deakin CD, De Buck ED, Dunning J, De Vries W, Evans TR, Eich C, Gräsner JT, Greif R, Hafner CM, Handley AJ, Haywood KL, Hunyadi-Antičević S, Koster RW, Lippert A, Lockey DJ, Lockey AS, López-Herce J, Lott C, Maconochie IK, Mentzelopoulos SD, Meyran D, Monsieurs KG, Nikolaou NI, Nolan JP, Olasveengen T, Paal P, Pellis T, Perkins GD, Rajka T, Raffay VI, Ristagno G, Rodríguez-Núñez A, Roehr CC, Rüdiger M, Sandroni C, Schunder-Tatzber S, Singletary EM, Skrifvars MB, Smith GB, Smyth MA, Soar J, Thies KC, Trevisanuto D, Truhlář A, Vandekerckhove PG, de Voorde PV, Sunde K, Urlesberger B, Wenzel V, Wyllie J, Xanthos TT, Zideman DA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation 2015; 95:1-80. [PMID: 26477410 DOI: 10.1016/j.resuscitation.2015.07.038] [Citation(s) in RCA: 564] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Koenraad G Monsieurs
- Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Robert Greif
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland
| | - Ian K Maconochie
- Paediatric Emergency Medicine Department, Imperial College Healthcare NHS Trust and BRC Imperial NIHR, Imperial College, London, UK
| | | | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Jonathan Wyllie
- Department of Neonatology, The James Cook University Hospital, Middlesbrough, UK
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Nikolaou NI, Arntz HR, Bellou A, Beygui F, Bossaert LL, Cariou A, Danchin N. European Resuscitation Council Guidelines for Resuscitation 2015 Section 8. Initial management of acute coronary syndromes. Resuscitation 2015; 95:264-77. [DOI: 10.1016/j.resuscitation.2015.07.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4224] [Impact Index Per Article: 469.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Maroules CD, Cury RC, Ghoshhajra BB, Hoffmann U, Litt HI, Blankstein R, Abbara S. Strategy for Building a Successful Coronary CT Angiography Program in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9337-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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35
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Updates on Coronary CTA in the Emergency Department. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0096-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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36
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Alexanderson-Rosas E, Guinto-Nishimura GY, Cruz-Mendoza JR, Oropeza-Aguilar M, De La Fuente-Mancera JC, Barrero-Mier AF, Monroy-Gonzalez A, Juarez-Orozco LE, Cano-Zarate R, Meave-Gonzalez A. Current and future trends in multimodality imaging of coronary artery disease. Expert Rev Cardiovasc Ther 2015; 13:715-31. [PMID: 25912725 DOI: 10.1586/14779072.2015.1039991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Nowadays, there is a wide array of imaging studies available for the evaluation of coronary artery disease, each with its particular indications and strengths. Cardiac single photon emission tomography is mostly used to evaluate myocardial perfusion, having experienced recent marked improvements in image acquisition. Cardiac PET has its main utility in perfusion imaging, atherosclerosis and endothelial function evaluation, and viability assessment. Cardiovascular computed tomography has long been used as a reference test for non-invasive evaluation of coronary lesions and anatomic characterization. Cardiovascular magnetic resonance is currently the reference standard for non-invasive ventricular function evaluation and myocardial scarring delineation. These specific strengths have been enhanced with the advent of hybrid equipment, offering a true integration of different imaging modalities into a single, simultaneous and comprehensive study.
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Affiliation(s)
- Erick Alexanderson-Rosas
- Department of Nuclear Cardiology, Instituto Nacional de Cardiología 'Ignacio Chávez', Mexico City, Mexico
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Russell FM, Moore CL, Courtney DM, Kabrhel C, Smithline HA, Nordenholz KE, Richman PB, O'Neil BJ, Plewa MC, Beam DM, Mastouri R, Kline JA. Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath. Am J Emerg Med 2015; 33:542-7. [PMID: 25769797 PMCID: PMC7032017 DOI: 10.1016/j.ajem.2015.01.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/15/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. METHODS A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. RESULTS A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). CONCLUSION This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes.
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Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Christopher L Moore
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
| | - D Mark Courtney
- Department of Emergency Medicine, Northwestern University, Evanston, IL.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - Howard A Smithline
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA.
| | - Kristen E Nordenholz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Peter B Richman
- Department of Emergency Medicine, Texas A&M Health Science Center, Corpus Christi, TX.
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit, MI.
| | - Michael C Plewa
- Department of Emergency Medicine, Mercy St Vincent Mercy Medical Center, Toledo, OH.
| | - Daren M Beam
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Ronald Mastouri
- Department of Internal Medicine, Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
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Kim YJ, Yong HS, Kim SM, Kim JA, Yang DH, Hong YJ. Korean guidelines for the appropriate use of cardiac CT. Korean J Radiol 2015; 16:251-85. [PMID: 25741189 PMCID: PMC4347263 DOI: 10.3348/kjr.2015.16.2.251] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 01/03/2015] [Indexed: 01/07/2023] Open
Abstract
The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
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Affiliation(s)
- Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul 152-703, Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Jeong A Kim
- Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 411-706, Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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El-Hayek G, Benjo A, Uretsky S, Al-Mallah M, Cohen R, Bamira D, Chavez P, Nascimento F, Santana O, Patel R, Cavalcante JL. Meta-analysis of coronary computed tomography angiography versus standard of care strategy for the evaluation of low risk chest pain: Are randomized controlled trials and cohort studies showing the same evidence? Int J Cardiol 2014; 177:238-45. [DOI: 10.1016/j.ijcard.2014.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/24/2014] [Accepted: 09/15/2014] [Indexed: 11/30/2022]
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Liu CH, Sastre A, Conroy R, Seto B, Pettigrew RI. NIH workshop on clinical translation of molecular imaging probes and technology--meeting report. Mol Imaging Biol 2014; 16:595-604. [PMID: 24833042 PMCID: PMC4161932 DOI: 10.1007/s11307-014-0746-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A workshop on "Clinical Translation of Molecular Imaging Probes and Technology" was held August 2, 2013 in Bethesda, Maryland, organized and supported by the National Institute of Biomedical Imaging and Bioengineering (NIBIB). This workshop brought together researchers, clinicians, representatives from pharmaceutical companies, molecular probe developers, and regulatory science experts. Attendees met to talk over current challenges in the discovery, validation, and translation of molecular imaging (MI) probes for key clinical applications. Participants also discussed potential strategies to address these challenges. The workshop consisted of 4 sessions, with 14 presentations and 2 panel discussions. Topics of discussion included (1) challenges and opportunities for clinical research and patient care, (2) advances in molecular probe design, (3) current approaches used by industry and pharmaceutical companies, and (4) clinical translation of MI probes. In the presentations and discussions, there were general agreement that while the barriers for validation and translation of MI probes remain high, there are pressing clinical needs and development opportunities for targets in cardiovascular, cancer, endocrine, neurological, and inflammatory diseases. The strengths of different imaging modalities, and the synergy of multimodality imaging, were highlighted. Participants also underscored the continuing need for close interactions and collaborations between academic and industrial partners, and federal agencies in the imaging probe development process.
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Affiliation(s)
- Christina H Liu
- National Institute of Biomedical Imaging and Bioengineering, 6707 Democracy Blvd., Suite 200, Bethesda, MD, 20892, USA,
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Duvall WL, Savino JA, Levine EJ, Baber U, Lin JT, Einstein AJ, Hermann LK, Henzlova MJ. A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department. J Nucl Cardiol 2014; 21:305-18. [PMID: 24310280 DOI: 10.1007/s12350-013-9823-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population. METHODS In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups. RESULTS A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P = .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P = .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P = .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort. CONCLUSIONS Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing.
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Affiliation(s)
- W Lane Duvall
- Mount Sinai Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, One Gustave L Levy Place, Box 1030, New York, NY, 10029, USA,
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Abstract
As laparoscopic surgery is replacing open surgery, similarly computed tomography angiography is replacing invasive conventional cardiac angiography. In the last century, marvelous efforts in research have improved strategies for cure, diagnosis and prevention of fatal human diseases; however, coronary artery disease, as the most prevalent cause of mortality and morbidity in the world, has remained a great challenge. Due to advancements in technology and research, it has become more simple and robust to diagnose and treat coronary artery disease (CAD) with minimal or no intervention, promising to not only diagnosis at an early stage but potential prevention altogether. While most with obvious CAD can be diagnosed easily and quickly with ECG, those identified as 'low risk' require more extensive testing to diagnose or rule out CAD. For example in emergency departments, low-risk patients with chest pain are diagnosed solely depending on history, ECG and blood testing for biomarkers. This approach has resulted in either delayed or miss-diagnosis of Acute coronary syndrome. To prevent this, many emergency departments now use protocols for low-risk heart patients that include cardiac stress tests and/or CT heart imaging. This review provides an overview of the current literature on the value of Computed tomography angiography and discusses how prognostic information obtained with Computed tomography angiography can be used to further integrate the technique into clinical practice.
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Affiliation(s)
- Muhammad A Latif
- St. John Cardiovascular Research Center, Los Angeles Biomedical Research Institute, Torrance, CA, USA
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Use of multi-slice computed tomography in patients with chest-pain submitted to the emergency department. Int J Cardiovasc Imaging 2013; 30:145-53. [DOI: 10.1007/s10554-013-0292-9] [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] [Received: 05/22/2013] [Accepted: 09/05/2013] [Indexed: 10/26/2022]
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Bilolikar AN, Chinnaiyan KM. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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45
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Maroules CD, Blaha MJ, El-Haddad MA, Ferencik M, Cury RC. Establishing a successful coronary CT angiography program in the emergency department: Official writing of the Fellow and Resident Leaders of the Society of Cardiovascular Computed Tomography (FiRST). J Cardiovasc Comput Tomogr 2013; 7:150-6. [DOI: 10.1016/j.jcct.2013.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 03/08/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022]
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Otaki Y, Berman DS, Min JK. Prognostic utility of coronary computed tomographic angiography. Indian Heart J 2013; 65:300-10. [PMID: 23809386 DOI: 10.1016/j.ihj.2013.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 04/08/2013] [Accepted: 04/08/2013] [Indexed: 01/11/2023] Open
Abstract
Coronary computed tomographic angiography (CCTA) employing CT scanners of 64-detector rows or greater represents a noninvasive method that enables accurate detection and exclusion of anatomically obstructive coronary artery disease (CAD), providing excellent diagnostic information when compared to invasive angiography. There are numerous potential advantages of CCTA beyond simply luminal stenosis assessment including quantification of atherosclerotic plaque volume as well as assessment of plaque composition, extent, location and distribution. In recent years, an array of studies has evaluated the prognostic utility of CCTA findings of CAD for the prediction of major adverse cardiac events, all-cause death and plaque instability. This prognostic information enhances risk stratification and, if properly acted upon, may improve medical therapy and/or behavioral changes that may enhance event-free survival. The goal of the present article is to summarize the current status of the prognostic utility of CCTA findings of CAD.
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Affiliation(s)
- Yuka Otaki
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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McBride CB, Cheezum MK, Gore RS, Pathirana IN, Slim AM, Villines TC. Coronary Artery Calcium Testing in Symptomatic Patients: An Issue of Diagnostic Efficiency. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013; 6:211-220. [PMID: 23795234 PMCID: PMC3683145 DOI: 10.1007/s12410-013-9198-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The detection and quantification of coronary artery calcification (CAC) significantly improves cardiovascular risk prediction in asymptomatic patients. Many have advocated for expanded CAC testing in symptomatic patients based on data demonstrating that the absence of quantifiable CAC in patients with possible angina makes obstructive coronary artery disease (CAD) and subsequent adverse events highly unlikely. However, the widespread use of CAC testing in symptomatic patients may be limited by the high background prevalence of CAC and its low specificity for obstructive CAD, necessitating additional testing ('test layering') in a large percentage of eligible patients. Further, adequately powered prospective studies validating the comparative effectiveness of a 'CAC first' approach with regards to cost, safety, accuracy and clinical outcomes are lacking. Due to marked reductions in patient radiation exposure and higher comparative accuracy and prognostic value make coronary computed tomographic angiography the preferred CT-based test for appropriately selected symptomatic patients.
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Affiliation(s)
- Chad B McBride
- Cardiology Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue., Bethesda, MD 20850 USA
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Outcomes After Coronary Computed Tomography Angiography in the Emergency Department. J Am Coll Cardiol 2013; 61:880-92. [DOI: 10.1016/j.jacc.2012.11.061] [Citation(s) in RCA: 186] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/06/2012] [Accepted: 11/08/2012] [Indexed: 12/12/2022]
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Chinnaiyan KM, Raff GL, Ananthasubramaniam K. Coronary CT angiography after stress testing: an efficient use of resources? Implications of the Advanced Cardiovascular Imaging Consortium (ACIC) results. J Nucl Cardiol 2012; 19:649-57. [PMID: 22648288 DOI: 10.1007/s12350-012-9578-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Coronary CT angiography (CCTA) has matured to be a fast noninvasive imaging test in the evaluation of coronary artery disease (CAD). It has demonstrated excellent accuracy for defining the presence and the severity of luminal coronary artery stenoses and is probably the best noninvasive test to reliably exclude atherosclerotic coronary disease. Furthermore, accumulating CCTA data indicate that it can identify individuals at risk for all-cause mortality. It is also well known that despite the wealth of data regarding diagnostic and prognostic values of stress testing in CAD, up to 10% of stress imaging studies are considered inconclusive, leading to subsequent invasive coronary angiography for definitive diagnosis often with negative results. Moreover, recent data indicate that up to 30 % of patients undergoing angiography have no significant CAD despite a majority of them having had a prior stress test. Whether CCTA can serve as a cost-effective methodology to invasive angiography has been a source of active research. In this context, we will discuss the implications of the recently published data from the Advanced Cardiovascular Imaging Consortium registry looking at the use of CCTA after stress testing in Michigan.
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