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Diagnostic and Management Strategies in Patients with Late Recurrent Angina after Coronary Artery Bypass Grafting. Curr Cardiol Rep 2022; 24:1309-1325. [PMID: 35925511 PMCID: PMC9556385 DOI: 10.1007/s11886-022-01746-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/04/2022]
Abstract
Purpose of Review This review will outline the current evidence on the anatomical, functional, and physiological tools that may be applied in the evaluation of patients with late recurrent angina after coronary artery bypass grafting (CABG). Furthermore, we discuss management strategies and propose an algorithm to guide decision-making for this complex patient population. Recent Findings Patients with prior CABG often present with late recurrent angina as a result of bypass graft failure and progression of native coronary artery disease (CAD). These patients are generally older, have a higher prevalence of comorbidities, and more complex atherosclerotic lesion morphology compared to CABG-naïve patients. In addition, guideline recommendations are based on studies in which post-CABG patients have been largely excluded. Summary Several invasive and non-invasive diagnostic tools are currently available to assess graft patency, the hemodynamic significance of native CAD progression, left ventricular function, and myocardial viability. Such tools, in particular the latest generation coronary computed tomography angiography, are part of a systematic diagnostic work-up to guide optimal repeat revascularization strategy in patients presenting with late recurrent angina after CABG.
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de Winter RW, Schumacher SP, van Diemen PA, Jukema RA, Somsen YB, Stuijfzand WJ, Driessen RS, Bom MJ, Everaars H, van Rossum AC, van de Ven PM, Opolski MP, Verouden NJ, Danad I, Raijmakers PG, Nap A, Knaapen P. Impact of percutaneous coronary intervention of chronic total occlusions on absolute perfusion in remote myocardium. EUROINTERVENTION 2022; 18:e314-e323. [PMID: 34866043 PMCID: PMC9912974 DOI: 10.4244/eij-d-21-00702] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Revascularisation of a chronic total coronary occlusion (CTO) impacts the coronary physiology of the remote myocardial territory. AIMS This study aimed to evaluate the intrinsic effect of CTO percutaneous coronary intervention (PCI) on changes in absolute perfusion in remote myocardium. METHODS A total of 164 patients who underwent serial [15O]H2O positron emission tomography (PET) perfusion imaging at baseline and three months after successful single-vessel CTO PCI were included to evaluate changes in hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in the remote myocardium supplied by both non-target coronary arteries. RESULTS Perfusion indices in CTO and remote myocardium showed a positive correlation before (resting MBF: r=0.84, hMBF: r=0.75, and CFR: r=0.77, p<0.01 for all) and after (resting MBF: r=0.87, hMBF: r=0.87, and CFR: r=0.81, p<0.01 for all) CTO PCI. Absolute increases in hMBF and CFR were observed in remote myocardium following CTO revascularisation (from 2.29±0.67 to 2.48±0.75 mL·min-1·g-1 and from 2.48±0.76 to 2.74±0.85, respectively, p<0.01 for both). Improvements in remote myocardial perfusion were largest in patients with a higher increase in hMBF (β 0.58, 95% CI: 0.48-0.67, p<0.01) and CFR (β 0.54, 95% CI: 0.44-0.64, p<0.01) in the CTO territory, independent of clinical, angiographic and procedural characteristics. CONCLUSIONS CTO revascularisation resulted in an increase in remote myocardial perfusion. Furthermore, the quantitative improvement in hMBF and CFR in the CTO territory was independently associated with the absolute perfusion increase in remote myocardial regions. As such, CTO PCI may have a favourable physiologic impact beyond the intended treated myocardium.
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Affiliation(s)
- Ruben W. de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan P. Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pepijn A. van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruurt A. Jukema
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Yvemarie B.O. Somsen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wynand J. Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S. Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel J. Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Peter M. van de Ven
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Maksymilian P. Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Niels J. Verouden
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G. Raijmakers
- Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Alex Nap
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology Heart Center, Amsterdam UMC, location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
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Brandt MM, Cheng C, Merkus D, Duncker DJ, Sorop O. Mechanobiology of Microvascular Function and Structure in Health and Disease: Focus on the Coronary Circulation. Front Physiol 2022; 12:771960. [PMID: 35002759 PMCID: PMC8733629 DOI: 10.3389/fphys.2021.771960] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022] Open
Abstract
The coronary microvasculature plays a key role in regulating the tight coupling between myocardial perfusion and myocardial oxygen demand across a wide range of cardiac activity. Short-term regulation of coronary blood flow in response to metabolic stimuli is achieved via adjustment of vascular diameter in different segments of the microvasculature in conjunction with mechanical forces eliciting myogenic and flow-mediated vasodilation. In contrast, chronic adjustments in flow regulation also involve microvascular structural modifications, termed remodeling. Vascular remodeling encompasses changes in microvascular diameter and/or density being largely modulated by mechanical forces acting on the endothelium and vascular smooth muscle cells. Whereas in recent years, substantial knowledge has been gathered regarding the molecular mechanisms controlling microvascular tone and how these are altered in various diseases, the structural adaptations in response to pathologic situations are less well understood. In this article, we review the factors involved in coronary microvascular functional and structural alterations in obstructive and non-obstructive coronary artery disease and the molecular mechanisms involved therein with a focus on mechanobiology. Cardiovascular risk factors including metabolic dysregulation, hypercholesterolemia, hypertension and aging have been shown to induce microvascular (endothelial) dysfunction and vascular remodeling. Additionally, alterations in biomechanical forces produced by a coronary artery stenosis are associated with microvascular functional and structural alterations. Future studies should be directed at further unraveling the mechanisms underlying the coronary microvascular functional and structural alterations in disease; a deeper understanding of these mechanisms is critical for the identification of potential new targets for the treatment of ischemic heart disease.
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Affiliation(s)
- Maarten M Brandt
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Caroline Cheng
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Division of Internal Medicine and Dermatology, Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Walter Brendel Center of Experimental Medicine (WBex), LMU Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Oana Sorop
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Luu JM, Schmidt A, Flewitt J, Mikami Y, Ter Keurs H, Friedrich MG. Cardiovascular risk is associated with a transmural gradient of myocardial oxygenation during adenosine infusion. Eur Heart J Cardiovasc Imaging 2020; 20:1287-1295. [PMID: 30590548 DOI: 10.1093/ehjci/jey202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/17/2018] [Indexed: 11/12/2022] Open
Abstract
AIMS In patients with coronary artery disease (CAD), a transmural gradient of myocardial perfusion has been repeatedly observed, with the subendocardial layer showing more pronounced perfusion deficits. Oxygenation-sensitive cardiovascular magnetic resonance (OS-CMR) allows for monitoring transmural changes of myocardial oxygenation in vivo. We hypothesized that OS-CMR could help identify a transmural oxygenation gradient as a disease marker in patients at risk for CAD. METHODS AND RESULTS We assessed 34 patients with known CAD and 28 subjects with coronary risk factors but no evidence of significant CAD. Results were compared with 11 healthy volunteers. OS-CMR was performed at 1.5 T, applying a T2*-weighted cine steady state free precession sequence at baseline and during infusion of adenosine. A reader blinded to patient data quantified the relative change of myocardial oxygenation in OS-CMR, defined by the change of signal intensity (ΔSI%) between baseline and during adenosine infusion in the entire myocardium, the subepicardial layer, and the subendocardial layer. SI changes were homogenous throughout the myocardium in healthy subjects, whereas both, patients with risk factors only and patients with CAD, had a significantly smaller ΔSI% in the subendocardial layer than in the subendocardial layer. Both patient groups had an overall decreased ΔSI% across all layers when compared with healthy subjects (P < 0.05). CONCLUSION Even in the absence of overt CAD, cardiovascular risk factors are associated with a transmural gradient of the myocardial oxygenation response to adenosine as assessed by OS-CMR. An inducible transmural oxygenation gradient may serve as a non-invasive marker for cardiovascular risk.
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Affiliation(s)
- Judy M Luu
- Division of Cardiology, Department of Medicine, University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, Canada
| | - Anna Schmidt
- Department of Cardiac Sciences, Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, Suite 0700-SSB, 1403-29th Street NW, Calgary AB, Canada
| | - Jacqueline Flewitt
- Department of Cardiac Sciences, Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, Suite 0700-SSB, 1403-29th Street NW, Calgary AB, Canada
| | - Yoko Mikami
- Department of Cardiac Sciences, Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, Suite 0700-SSB, 1403-29th Street NW, Calgary AB, Canada
| | - Henk Ter Keurs
- Department of Cardiac Sciences, Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, Suite 0700-SSB, 1403-29th Street NW, Calgary AB, Canada
| | - Matthias G Friedrich
- Departments of Cardiology and Diagnostic Radiology, McGill University Health Centre, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, Canada.,Department of Radiology, Université de Montréal, Pavillon Roger-Gaudry - Local S-716, Montréal QC, Canada.,Departments of Cardiac Sciences and Radiology, University of Calgary, 3330 Hospital Dr. NW, Calgary AB, Canada
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Sechtem U, Brown D, Godo S, Lanza GA, Shimokawa H, Sidik N. Coronary microvascular dysfunction in stable ischaemic heart disease (non-obstructive coronary artery disease and obstructive coronary artery disease). Cardiovasc Res 2020; 116:771-786. [PMID: 31958128 DOI: 10.1093/cvr/cvaa005] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
Diffuse and focal epicardial coronary disease and coronary microvascular abnormalities may exist side-by-side. Identifying the contributions of each of these three players in the coronary circulation is a difficult task. Yet identifying coronary microvascular dysfunction (CMD) as an additional player in patients with coronary artery disease (CAD) may provide explanations of why symptoms may persist frequently following and why global coronary flow reserve may be more prognostically important than fractional flow reserve measured in a single vessel before percutaneous coronary intervention. This review focuses on the challenges of identifying the presence of CMD in the context of diffuse non-obstructive CAD and obstructive CAD. Furthermore, it is going to discuss the pathophysiology in this complex situation, examine the clinical context in which the interaction of the three components of disease takes place and finally look at non-invasive diagnostic methods relevant for addressing this question.
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Affiliation(s)
- Udo Sechtem
- Department of Cardiology, Robert Bosch Krankenhaus, Auerbachstr. 110, D-70376 Stuttgart, Germany
| | - David Brown
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Cardiology Institute, Roma, Italy
| | - Hiro Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Novalia Sidik
- University of Glasgow, Golden Jubilee National Hospital, Glasgow, UK
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Abstract
In recent years, it has become apparent that coronary microvascular dysfunction plays a pivotal pathogenic role in angina pectoris. Functional and structural mechanisms can affect the physiological function of the coronary microvasculature and lead to myocardial ischemia in people without coronary atheromatous disease and also in individuals with obstructive coronary artery disease. Abnormal dilatory responses of the coronary microvessels, coronary microvascular spasm, and extravascular compressive forces have been identified as pathogenic mechanisms in both chronic and acute forms of ischemic heart disease. The condition characterized by anginal symptoms and evidence of myocardial ischemia triggered by coronary microvascular dysfunction, in the absence of obstructive coronary disease, is known as microvascular angina. The concept of microvascular angina, however, may extend further to include patients with obstructive coronary artery disease and individuals with angina after coronary revascularization or heart transplantation because coronary microvascular dysfunction contributes to myocardial ischemia in many such patients. Patients with microvascular angina constitute a sizeable proportion of all cases of stable angina undergoing diagnostic coronary angiography and of those with persisting angina after successful coronary revascularization. Coronary microvascular dysfunction is also often responsible for angina in individuals with cardiomyopathy and heart valve disease as well as acute coronary syndrome cases such as Takotsubo syndrome and myocardial infarction with no obstructive coronary artery disease. Patients with stable microvascular angina present typically with effort or rest chest pain and a reduced coronary flow reserve or microvascular spasm. This condition, which affects women and men, can markedly impair quality of life and prognosis and represents a substantial cost burden to healthcare systems and individuals alike. In recent years, progress in the diagnosis of myocardial ischemia and the use of tests to investigate functional and structural causes for a reduced coronary flow reserve and microvascular spasm have allowed the identification of an increased number of cases of microvascular angina in everyday clinical practice. Although some of the available anti-anginal drugs may be helpful, treatment of coronary microvascular dysfunction remains a major challenge. The present article discusses the fundamental role that coronary microvascular dysfunction plays in the pathogenesis of ischemic heart disease, the clinical characteristics of patients presenting with microvascular angina, and possible diagnostic and therapeutic strategies.
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Affiliation(s)
- Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom (J.-C.K)
| | - Filippo Crea
- Institute of Cardiology, Catholic University, Rome, Italy (F.C.)
| | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN (B.J.G.)
| | - Paolo G Camici
- Vita-Salute University and Department of Cardiology San Raffaele Hospital, Milan, Italy (P.G.C.)
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Iodine quantification based on rest / stress perfusion dual energy CT to differentiate ischemic, infarcted and normal myocardium. Eur J Radiol 2019; 112:136-143. [PMID: 30777202 DOI: 10.1016/j.ejrad.2019.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/06/2018] [Accepted: 01/15/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to assess the potential of rest-stress DECT iodine quantification to discriminate between normal, ischemic, and infarcted myocardium. METHODS Patients who underwent rest-stress DECT on a 2nd generation dual-source system and cardiac magnetic resonance (CMR) were retrospectively included from a prospective study cohort. CMR was performed to identify ischemic and infarcted myocardium and categorize patients into ischemic, infarcted, and control groups. Controls were analyzed on a per-slice and per-segment basis. Regions of interest (ROIs) were placed in ischemic and infarcted areas based on CMR. Additionally, ROIs were placed in the septal area to assess normal and remote myocardium. RESULTS We included 42 patients: 10 ischemic, 17 infarcted, and 15 controls. Iodine concentrations showed no significant between segments in controls. Iodine concentrations for normal myocardium increased significantly from rest to stress (median 3.7 mg/mL (interquartile range 3.5-3.9) vs. 4.5 mg/mL (4.3-4.9)) (p < 0.001). Iodine concentrations in diseased myocardium were significantly lower than in normal myocardium; 1.3 mg/mL (0.9-1.8) and 0.6 mg/mL (0.4-0.8) at rest and stress in ischemic myocardium, and 0.3 mg/mL (0.3-0.5) and 0.5 mg/mL (0.5-0.7) at rest and stress in infarcted myocardium (p < 0.005 and p < 0.001). At rest only, iodine concentrations were significantly lower in infarcted vs. ischemic myocardium (p < 0.001). The optimal threshold for differentiating diseased from normal myocardium was 2.5 mg/mL and 2.1 mg/mL for rest and stress (AUC 1.00). To discriminate ischemic from infarcted myocardium, the optimal threshold was 1.0 mg/ml (AUC 0.944) at rest. CONCLUSION DECT iodine concentration from rest-stress imaging can potentially differentiate between normal, ischemic, and infarcted myocardium.
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Nudi F, Schilllaci O, Biondi-Zoccai G, Pinto A, Neri G, Procaccini E, Versaci F, Nudi A, Tomai F, Frati G, Iskandrian AE. Impact of specific coronary lesions on regional ischemia at single photon emission computed tomography. J Cardiovasc Med (Hagerstown) 2018; 19:329-336. [PMID: 29846303 DOI: 10.2459/jcm.0000000000000675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS Prior studies using stress myocardial perfusion imaging (MPI), which examined the association between obstructive epicardial coronary disease and presence of myocardial ischemia did not provide a detailed assessment on a regional level. We examined this relationship in a large population of patients in whom the coronary anatomy was defined by invasive coronary angiography. METHODS We retrospectively extracted details on individuals undergoing MPI with single photon emission computed tomography (SPECT) who had coronary angiography within 12 months. A 17-segment model for native coronary anatomy and a 7-region model for myocardial perfusion were used with a dedicated matching algorithm. RESULTS A total of 2564 patients were included, yielding a total of 6279 stenoses matched with 17 948 myocardial regions. From such a cohort, 151 (5.9%) patients had normal perfusion, 1878 (73.2%) had myocardial ischemia (reversible defects), 260 (10.1%) had myocardial necrosis (scar or fixed defects), and 275 (10.7%) had ischemia and necrosis. At per-patient analysis, significant angiographic disease was more common in the ischemic group (prevalence between 69.6 and 80.0%) than other groups. At per-region analysis, abnormal perfusion in the coronary-specific regions varied depending on location of stenosis; it was 96% for left main disease, 81% for proximal left anterior descending disease, 85% for proximal left circumflex disease, and 82% for proximal right coronary artery disease and <60% for posterior descending artery disease. CONCLUSION The correlation between significant coronary stenosis and presence of corresponding regional perfusion abnormality depends on the location of the lesion and the corresponding myocardial region.
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Affiliation(s)
- Francesco Nudi
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic.,ETISAN
| | | | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina.,Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli
| | - Annamaria Pinto
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic.,Ostia Radiologica, Rome
| | | | | | | | | | | | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina.,Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Alabama, USA
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Benenati S, De Maria GL, Scarsini R, Porto I, Banning AP. Invasive “in the cath-lab” assessment of myocardial ischemia in patients with coronary artery disease: When does the gold standard not apply? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:362-372. [DOI: 10.1016/j.carrev.2018.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
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10
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Rimoldi O, Camici PG. The beginning at the end: non-invasive assessment of post-transplant coronary allograft vasculopathy at the microcirculatory level. Eur Heart J 2018; 39:324-326. [PMID: 29351613 DOI: 10.1093/eurheartj/ehx738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ornella Rimoldi
- CNR IBFM, Segrate, Italy.,Vita-Salute University Milan, Italy
| | - Paolo G Camici
- Vita-Salute University Milan, Italy.,Ospedale San Raffaele, IRCCS Milan, Italy
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The value of real-time myocardial contrast echocardiography for detecting coronary microcirculation function in coronary artery disease patients. Anatol J Cardiol 2018; 19:27-33. [PMID: 29339697 PMCID: PMC5864787 DOI: 10.14744/anatoljcardiol.2017.8041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective: The aim of this study was to evaluate the value of real-time myocardial contrast echocardiography (RT-MCE) for detecting coronary microcirculation (CM) function in coronary artery disease (CAD) patients. Methods: Sixty-five consecutive patients were divided into CAD (n=52) and no-CAD (n=13) groups using coronary angiography (CAG). All patients underwent RT-MCE at rest and CAG within 1 week after RT-MCE. The ventricular segments in CAD patients were divided semi-quantitatively into ischemic and non-ischemic myocardial groups based on RT-MCE images. Myocardial blood volume (A), myocardial blood flow velocity (β), and mean myocardial blood flow (A×β) were obtained. The Gensini scores were calculated for CAD patients. The receiver operating characteristic (ROC) curve areas of A, β, and A×β were calculated to assess CM function in CAD patients. Results: A total of 798 and 204 segments were investigated in the CAD and non-CAD groups, respectively. In CAD patients, 332 ischemic and 466 non-ischemic segments were identified. The values of A, β, and A×β were significantly different among non-CAD, CAD, ischemic, and non-ischemic groups. ROC curve areas of A, β, and A×β were 0.85, 0.79, and 0.83, respectively, and significant differences were observed in these values among three Gensini score groups of the CAD patients. Conclusion: Varying degrees of CM function deterioration was observed in CAD patients both in ischemic and non-ischemic areas, with the deterioration being more sever in the former.
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12
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Stenström I, Maaniitty T, Uusitalo V, Pietilä M, Ukkonen H, Kajander S, Mäki M, Bax JJ, Knuuti J, Saraste A. Frequency and angiographic characteristics of coronary microvascular dysfunction in stable angina: a hybrid imaging study. Eur Heart J Cardiovasc Imaging 2017; 18:1206-1213. [DOI: 10.1093/ehjci/jex193] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/10/2017] [Indexed: 01/07/2023] Open
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13
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Estimation of myocardial flow reserve utilizing an ultrafast cardiac SPECT: Comparison with coronary angiography, fractional flow reserve, and the SYNTAX score. Int J Cardiol 2017. [PMID: 28622946 DOI: 10.1016/j.ijcard.2017.06.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Quantitative assessment of myocardial flow reserve (MFR) by single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is challenging but may facilitate evaluation of multi-vessel coronary artery disease (CAD). METHODS We enrolled 153 patients with suspected or known CAD, referred for pharmacological stress MPI. They underwent a 99mTc-perfusion stress/rest SPECT with an ultrafast cadmium-zinc-telluride (CZT) camera. Dynamic data were acquired and time-activity curves fitted to a 1-tissue compartment analysis with input function. K1 was assigned for stress and rest data. The MFR index (MFRi) was calculated as K1 stress/K1 at-rest. The findings were validated by invasive coronary angiography in 69 consecutive patients. RESULTS The global MFRi was 1.46 (1.16-1.76), 1.33 (1.12-1.54), and 1.18 (1.01-1.35), for 1-vessel disease (VD), 2-VD, and 3-VD, respectively. In the 3-VD, global MFRi was lower than that in 0-VD (1.63 [1.22-2.04], P<0.0001) and 1-VD (P=0.003). Multivariate logistic regression analysis for 3-VD showed significant associations with smoking history (odds ratio [OR]: 4.4 [0.4-8.4]), left ventricular ejection fraction (OR: 61.6 [57.5-66.0]), and global MFRi (OR: 119.6 [111.5-127.7], P=0.002). A cut-off value of 1.3 yielded 93.3% sensitivity and 75.9% specificity for diagnosing 3-VD. Fractional flow reserve positively correlated with regional MFRi (r=0.62, P=0.008), and the SYNTAX score correlated negatively with global MFRi (r=0.567, P=0.0003). CONCLUSION We developed and validated a clinically available method for MFR quantification by dynamic 99mTc-perfusion SPECT utilizing a CZT camera, which improves the detectability of multi-vessel CAD.
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De Vita A, Milo M, Sestito A, Lamendola P, Lanza GA, Crea F. Association of coronary microvascular dysfunction with restenosis of left anterior descending coronary artery disease treated by percutaneous intervention. Int J Cardiol 2016; 219:322-5. [DOI: 10.1016/j.ijcard.2016.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
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15
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Coronary flow velocity reserve by echocardiography: feasibility, reproducibility and agreement with PET in overweight and obese patients with stable and revascularized coronary artery disease. Cardiovasc Ultrasound 2016; 14:22. [PMID: 27267255 PMCID: PMC4897868 DOI: 10.1186/s12947-016-0066-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/01/2016] [Indexed: 11/15/2022] Open
Abstract
Background Coronary flow velocity reserve (CFVR) measured by transthoracic Doppler echocardiography of the LAD is used to assess microvascular function but validation studies in clinical settings are lacking. We aimed to assess feasibility, reproducibility and agreement with myocardial flow reserve (MFR) measured by PET in overweight and obese patients. Methods Participants with revascularized coronary artery disease were examined by CFVR. Subgroups were examined by repeated CFVR (reproducibility) or Rubidium-82-PET (agreement). To account for time variation, results were computed for scans performed within a week (1-week) and for all scans regardless of time gap (total) and to account for scar tissue for patients with and without previous myocardial infarction (MI). Results Eighty-six patients with median BMI 30.9 (IQR 29.4–32.9) kg × m−2 and CFVR 2.29 (1.90–2.63) were included. CFVR was feasible in 83 (97 %) using a contrast agent in 14 %. For reproducibility overall (n = 21) limits of agreement (LOA) were (−0.75;0.71), within-subjects coefficient of variation (CV) 11 %, and reliability 0.84. For reproducibility within 1-week (n = 13) LOA were (−0.33;0.25), within-subjects CV 5 %, and reliability 0.97. Agreement with MFR of the LAD territory (n = 35) was without significant bias and overall LOA were (−1.40;1.46). Agreement was best for examinations performed within 1-week of participants without MI of the LAD-territory (n = 12); LOA = (−0.68;0.88). Conclusions CFVR was highly feasible with a good reproducibility on par with other contemporary measures applied in cardiology. Agreement with MFR was acceptable, though discrepancy related to prior MI has to be considered. CFVR of LAD is a valid tool in overweight and obese patients.
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Nudi F, Schillaci O, Neri G, Pinto A, Procaccini E, Vetere M, Frati G, Tomai F, Biondi-Zoccai G. Prognostic impact of location and extent of vessel-related ischemia at myocardial perfusion scintigraphy in patients with or at risk for coronary artery disease. J Nucl Cardiol 2016; 23:274-84. [PMID: 25827620 DOI: 10.1007/s12350-015-0077-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Myocardial perfusion scintigraphy (MPS) has an established diagnostic and prognostic role in patients with or at risk for coronary artery disease, with ischemia severity and extent having already been identified as key predictors. Whether this is affected by the location of myocardial ischemia is uncertain. We aimed at comparing the prognostic outlook of patients undergoing MPS according to the site of ischemia. METHODS Our institutional database was queried for subjects undergoing MPS, without myocardial necrosis or recent revascularization. We focused on the prognostic impact of location of vessel-related ischemia (VRI) at MPS, distinguishing four mutually exclusive groups: single-VRI involving left anterior descending (LAD), single-VRI not involving LAD, multi-VRI involving LAD, and multi-VRI not involving LAD. The primary outcome was the long-term (>1 year) rate of death or myocardial infarction (D/MI). RESULTS A total of 13,254 patients were included. Moderate or severe VRI occurred in 2,627 (20%) patients. Clinical outcomes were significantly different among the groups of patients with moderate or severe VRI, including death, cardiac death, non-fatal myocardial infarction or their composites (overall P < .001). Specifically, and excluding subjects undergoing revascularization as first follow-up event, D/MI occurred in 8.4% of patients with single-VRI involving LAD, 5.5% of subjects with single-VRI not involving LAD, 16.5% of those with multi-VRI involving LAD, and 7.3% of patients with multi-VRI not involving LAD (overall P < .001). Even at incremental multivariable Cox proportional analysis, hierarchical VRI was independently associated with an increased risk of D/MI [hazard ratio = 1.17 (1.04-1.08) for each class increment, P = .010]. CONCLUSIONS Location and extent of myocardial ischemia at MPS according to the VRI concept have a hierarchical predictive impact, with multi-VRI involving LAD being significantly and independently more prognostically ominous than other types of VRI.
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Affiliation(s)
- Francesco Nudi
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Via Cesare Correnti 6, 00179, Rome, Italy.
- ETISAN, Rome, Italy.
| | - Orazio Schillaci
- Institute of Nuclear Medicine, Tor Vergata University, Rome, Italy
| | - Giandomenico Neri
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Via Cesare Correnti 6, 00179, Rome, Italy
| | - Annamaria Pinto
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Via Cesare Correnti 6, 00179, Rome, Italy
- Ostia Radiologica, Rome, Italy
| | - Enrica Procaccini
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Via Cesare Correnti 6, 00179, Rome, Italy
- Ostia Radiologica, Rome, Italy
| | - Maurizio Vetere
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Via Cesare Correnti 6, 00179, Rome, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | | | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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Briceno N, Schuster A, Lumley M, Perera D. Ischaemic cardiomyopathy: pathophysiology, assessment and the role of revascularisation. Heart 2016; 102:397-406. [PMID: 26740480 DOI: 10.1136/heartjnl-2015-308037] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/07/2015] [Indexed: 01/03/2023] Open
Affiliation(s)
- Natalia Briceno
- British Heart Foundation Centre of Excellence and National Institute for Health Research Centre, Cardiovascular Division, St Thomas' Hospital Campus, King's College London, UK
| | - Andreas Schuster
- Department of Cardiology and Pneumology, Georg-August-University Göttingen and German Centre for Cardiovascular Research (DZHK, partner site Göttingen), Göttingen, Germany Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, St. Thomas' Hospital, King's College London, London, UK
| | - Matthew Lumley
- British Heart Foundation Centre of Excellence and National Institute for Health Research Centre, Cardiovascular Division, St Thomas' Hospital Campus, King's College London, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and National Institute for Health Research Centre, Cardiovascular Division, St Thomas' Hospital Campus, King's College London, UK
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Huqi A, Guarini G, Morrone D, Marzilli M. Prediction of Post Percutaneous Coronary Intervention Myocardial Ischaemia. Eur Cardiol 2016; 11:85-89. [PMID: 30310453 DOI: 10.15420/ecr.2016:27:2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Following revascularisation the majority of patients obtain symptom relief and improved quality of life. However, myocardial ischaemia may recur or persist in a significant patient subset. Symptom recurrence is usually attributed to inaccurate evaluation of epicardial stenosis, incomplete revascularisation or stent failure and disease progression. However, technological advances with modern imaging and/or physiological evaluation of epicardial plaques have not solved this issue. Conversely, recent clinical studies have shown that abnormal coronary vasomotion and increased myocardial resistance are frequent determinants of post-percutaneous coronary intervention (PCI) myocardial ischaemia. Strategies to enhance prediction of post-PCI angina include proper selection of patients undergoing revascularisation, construction of clinical prediction models, and further invasive evaluation at the time of coronary angiography in those with high likelihood.
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Affiliation(s)
- Alda Huqi
- Cardiac Care Unit, Santa Maria Maddalena Hospital, Pisa, Italy
| | | | | | - Mario Marzilli
- Cardiac Care Unit, Santa Maria Maddalena Hospital, Pisa, Italy
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Pepine CJ, Ferdinand KC, Shaw LJ, Light-McGroary KA, Shah RU, Gulati M, Duvernoy C, Walsh MN, Bairey Merz CN. Emergence of Nonobstructive Coronary Artery Disease: A Woman's Problem and Need for Change in Definition on Angiography. J Am Coll Cardiol 2015; 66:1918-33. [PMID: 26493665 PMCID: PMC4618799 DOI: 10.1016/j.jacc.2015.08.876] [Citation(s) in RCA: 220] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/12/2023]
Abstract
Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.
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Affiliation(s)
- Carl J Pepine
- Division of Cardiology, University of Florida, Gainesville, Florida.
| | | | - Leslee J Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Rashmee U Shah
- Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Martha Gulati
- The College of Medicine and The College of Clinical Public Health, The Ohio State University, Columbus, Ohio
| | - Claire Duvernoy
- Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
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Intracoronary administration of nicorandil during primary percutaneous coronary intervention: Impact on restoration of regional myocardial perfusion in reperfused myocardium during the subacute phase of myocardial infarction. IJC HEART & VASCULATURE 2015; 8:81-86. [PMID: 28785685 PMCID: PMC5497254 DOI: 10.1016/j.ijcha.2015.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/25/2015] [Indexed: 12/05/2022]
Abstract
Background The impact of nicorandil as adjunctive therapy for percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) is controversial. We performed 15O-labeled water positron emission tomography (PET) to quantify regional myocardial perfusion in patients with STEMI who received nicorandil or no adjunctive therapy during PCI. Methods PCI was performed within 8 h after STEMI onset in 33 patients. 14 patients received intracoronary nicorandil 2 mg immediately after recanalization of the culprit lesion (Nico group). After 3–4 weeks, PET was performed in which myocardial blood flow (MBF) was measured at baseline and during adenosine triphosphate (ATP)-induced hyperemia. Myocardial vascular resistance (MVR) was calculated for all segments. Data were obtained from the reperfused (Rep) and normal segments (Cont) in each patient. Results In patients not given nicorandil (No-Nico group), the MBF was significantly lower in Rep than that in Cont at baseline and during hyperemia (Cont vs. Rep: 0.82 ± 0.14 vs. 0.68 ± 0.11, P = 0.001, ATP-Cont vs. ATP-Rep: 2.00 ± 0.72 vs. 1.52 ± 0.61, P = 0.017), which was restored in the Nico group (Cont vs. Rep: 0.79 ± 0.17 vs. 0.78 ± 0.20; ATP-Cont vs. ATP-Rep: 2.02 ± 0.84 vs. 1.84 ± 0.62). MVR was elevated in Rep at baseline and during hyperemia in the No-Nico group. MVR elevation in Rep was prevented in the Nico group. Conclusions 15O-labeled water PET was feasible for segmental analysis of MBF during the subacute phase of STEMI. It revealed that intracoronary administration of nicorandil to STEMI patients who underwent PCI prevented MVR elevation and thus restored MBF in the reperfused segments to a level similar to that in the normal segments. 15O-labeled water positron emission tomography (PET) is a tool to compare directly reperfused segments with normal segments simultaneously in each patient's hearts. 15O-labeled water PET permits noninvasive quantitative measurement of myocardial blood flow during the subacute phase of myocardial infarction. 15O-labeled water PET detects restoration of myocardial blood flow after intracoronary administration of nicorandil in STEMI patients.
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Teunissen PFA, Timmer SAJ, Danad I, de Waard GA, van de Ven PM, Raijmakers PG, Lammertsma AA, Van Rossum AC, van Royen N, Knaapen P. Coronary vasomotor function in infarcted and remote myocardium after primary percutaneous coronary intervention. Heart 2015; 101:1577-83. [DOI: 10.1136/heartjnl-2015-307825] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/09/2015] [Indexed: 11/04/2022] Open
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Thermodilutional Confirmation of Coronary Microvascular Dysfunction in Patients With Recurrent Angina After Successful Percutaneous Coronary Intervention. Can J Cardiol 2015; 31:989-97. [DOI: 10.1016/j.cjca.2015.03.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 12/27/2022] Open
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Olsen RH, Pedersen LR, Jürs A, Snoer M, Haugaard SB, Prescott E. A randomised trial comparing the effect of exercise training and weight loss on microvascular function in coronary artery disease. Int J Cardiol 2015; 185:229-35. [PMID: 25802037 DOI: 10.1016/j.ijcard.2015.03.118] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 03/07/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Coronary microvascular function is associated with outcome and is reduced in coronary artery disease (CAD) and obesity. We compared the effect of aerobic interval training (AIT) and weight loss on coronary flow reserve (CFR) and peripheral vascular function in revascularised obese CAD patients. METHODS AND RESULTS Seventy non-diabetic patients (BMI 28-40 kg × m(-2), age 45-75 years) were randomised to 12 weeks' AIT (three weekly sessions lasting 38 min with ≈ 16 min at 85-90% of VO2peak) or low energy diet (LED, 800-1000 kcal/day). Per protocol adherence was defined by training-attendance ≥ 60% and weight loss ≥ 5%, respectively. CFR was assessed by Doppler echocardiography of the LAD. Peripheral vascular function was assessed by arterial tonometry as reactive hyperaemia index (RHI) and augmentation index. Most participants had impaired CFR with a mean CFR of 2.38 (SD 0.59). Twenty-six AIT and 24 LED participants completed the study per protocol with valid CFR measurements. AIT resulted in a 10.4% improvement in VO2peak and LED in a 10.6% weight loss (between group differences both P<0.001). CFR increased by 0.26 (95%CI 0.04;0.48) after AIT and by 0.39 (95%CI 0.13;0.65) after LED without significant between-group difference (-0.13 (95%CI -0.45;0.20)). RHI and augmentation index remained unchanged after both interventions (P>0.50). Intention-to-treat analyses showed similar results. CONCLUSIONS 12 weeks' AIT and LED increased CFR by comparable magnitude; thus both interventions might impact prognosis of CAD through improvement of coronary microvascular function. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01724567.
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Affiliation(s)
- Rasmus Huan Olsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Lene Rørholm Pedersen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Jürs
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martin Snoer
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Steen B Haugaard
- Department of Internal Medicine, Amager Hospital & Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Klein R, Hung GU, Wu TC, Huang WS, Li D, deKemp RA, Hsu B. Feasibility and operator variability of myocardial blood flow and reserve measurements with ⁹⁹mTc-sestamibi quantitative dynamic SPECT/CT imaging. J Nucl Cardiol 2014; 21:1075-88. [PMID: 25280761 DOI: 10.1007/s12350-014-9971-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Accepted: 07/14/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE Myocardial blood flow (MBF) quantification with dynamic SPECT could lead to widespread utilization of MBF imaging in clinical practice with little cost increase over current standard SPECT myocardial perfusion imaging. This work evaluates the feasibility and operator-dependent variability of MBF and flow reserve measurements with (99m)Tc-sestamibi (MIBI) dynamic SPECT imaging using a standard dual-head SPECT camera. METHODS Twenty-eight patients underwent dipyridamole-stress and rest imaging with dynamic SPECT/CT acquisition. Quantitative images were iteratively reconstructed with all physical corrections and then myocardial and arterial blood regions of interest (ROI) were defined semi-automatically. A compartmental model was fitted to these ROI-sampled time-activity-curves, and flow-dependent MIBI extraction correction was applied to derive regional MBF values. Myocardial flow reserve (MFR) was estimated as stress/rest MBF ratio. MBF and MFR in low and high risk populations were evaluated for ability to detect disease. Images were each processed twice (≥7 days apart) by one expert and one novice operator to evaluate intra- and inter-operator variability of MBF and MFR measurement in the three coronary artery vascular territories. RESULTS Mean rest flow, stress flow, and MFR values were 0.83, 1.82 mL·minute(-1)·g(-1), and 2.45, respectively. For stress/rest MFR, the inter-operator reproducibility was r(2) = 0.86 with RPC = 1.1. Stress MBF and MFR were significantly reduced (P < .05) in high risk (n = 9) vs low risk populations (n = 19), indicating ability to detect disease. For expert and novice operators very good intra-operator correlations of r(2) = 0.98 and 0.95 (n = 168, P < .001) were observed for combined rest and stress regional flow values. Bland-Altman reproducibility coefficients (RPC) were 0.25 and 0.47 mL·minute(-1)·g(-1) for the expert and novice operators, respectively (P < .001). Inter-operator correlation was r(2) = 0.91 and Bland-Altman RPC = 0.58 mL·minute(-1)·g(-1) (n = 336). CONCLUSIONS MBF and reserve measurements using (99m)Tc-sestamibi on a traditional, two-headed camera with fast rotation and with quantitative dynamic SPECT appears to be feasible, warranting further investigation.
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Affiliation(s)
- Ran Klein
- University of Ottawa Heart Institute, Cardiac PET Centre, 40 Ruskin St., Ottawa, ON, K1Y 4W7, Canada,
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Camici PG, d'Amati G, Rimoldi O. Coronary microvascular dysfunction: mechanisms and functional assessment. Nat Rev Cardiol 2014; 12:48-62. [DOI: 10.1038/nrcardio.2014.160] [Citation(s) in RCA: 290] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Hennigan B, Layland J, Fearon WF, Oldroyd KG. Fractional flow reserve and the index of microvascular resistance in patients with acute coronary syndromes. EUROINTERVENTION 2014; 10 Suppl T:T55-63. [DOI: 10.4244/eijv10sta10] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lansky AJ, Ng VG, Meller S, Xu K, Fahy M, Feit F, Ohman EM, White HD, Mehran R, Bertrand ME, Desmet W, Hamon M, Stone GW. Impact of nonculprit vessel myocardial perfusion on outcomes of patients undergoing percutaneous coronary intervention for acute coronary syndromes: analysis from the ACUITY trial (Acute Catheterization and Urgent Intervention Triage Strategy). JACC Cardiovasc Interv 2014; 7:266-75. [PMID: 24650400 DOI: 10.1016/j.jcin.2013.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/08/2013] [Accepted: 08/30/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study evaluated the impact of nonculprit vessel myocardial perfusion on outcomes of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) patients. BACKGROUND ST-segment elevation myocardial infarction patients have decreased perfusion in areas remote from the infarct-related vessel. The impact of myocardial hypoperfusion of regions supplied by nonculprit vessels in NSTE-ACS patients treated with percutaneous coronary intervention (PCI) is unknown. METHODS The angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial included 6,921 NSTE-ACS patients. Complete 3-vessel assessments of baseline coronary TIMI (Thrombolysis In Myocardial Infarction) flow grade and myocardial blush grade (MBG) were performed. We examined the outcomes of PCI-treated patients according to the worst nonculprit vessel MBG identified per patient. RESULTS Among the 3,826 patients treated with PCI, the worst nonculprit MBG was determined in 3,426 (89.5%) patients, including 375 (10.9%) MBG 0/1 patients, 475 (13.9%) MBG 2 patients, and 2,576 (75.2%) MBG 3 patients. Nonculprit MBG 0/1 was associated with worse baseline clinical characteristics. Patients with nonculprit MBG 0/1 versus MBG 3 had increased rates of 30-day (3.0% vs. 0.7%, p < 0.0001) and 1-year (4.4% vs. 1.0%, p < 0.0001) death. Similar results were found among patients with pre-procedural TIMI flow grade 3 in the culprit vessel, where nonculprit vessel MBG 0/1 (hazard ratio: 2.81 [95% confidence interval: 1.63 to 4.84], p = 0.0002) was the strongest predictor of 1-year mortality. CONCLUSIONS Reduced myocardial perfusion in an area supplied by a nonculprit vessel is associated with increased short- and long-term mortality rates in NSTE-ACS patients undergoing PCI. Furthermore, worst nonculprit MBG is able to risk-stratify patients with normal baseline flow of the culprit vessel.
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Affiliation(s)
- Alexandra J Lansky
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
| | - Vivian G Ng
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Stephanie Meller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ke Xu
- Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
| | - Martin Fahy
- Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
| | - Frederick Feit
- Division of Cardiology, New York University School of Medicine, New York, New York
| | - E Magnus Ohman
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Roxana Mehran
- Division of Cardiology, Mount Sinai Medical Center, New York, New York
| | | | - Walter Desmet
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Martial Hamon
- Department of Cardiology, University Hospital, Normandy, France
| | - Gregg W Stone
- Division of Cardiology, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
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Milo M, Nerla R, Tarzia P, Infusino F, Battipaglia I, Sestito A, Lanza GA, Crea F. Coronary microvascular dysfunction after elective percutaneous coronary intervention: Correlation with exercise stress test results. Int J Cardiol 2013; 168:121-5. [DOI: 10.1016/j.ijcard.2012.09.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/27/2012] [Accepted: 09/14/2012] [Indexed: 11/30/2022]
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Reduced microvascular density in non-ischemic myocardium of patients with recent non-ST-segment-elevation myocardial infarction. Int J Cardiol 2013; 167:1027-37. [DOI: 10.1016/j.ijcard.2012.03.075] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 01/29/2012] [Accepted: 03/03/2012] [Indexed: 01/22/2023]
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Izzo P, Macchi A, De Gennaro L, Gaglione A, Di Biase M, Brunetti ND. Recurrent angina after coronary angioplasty: mechanisms, diagnostic and therapeutic options. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2012; 1:158-69. [PMID: 24062904 PMCID: PMC3760523 DOI: 10.1177/2048872612449111] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/30/2012] [Indexed: 01/03/2023]
Abstract
Recurrent angina in patients who underwent percutaneous coronary intervention is defined as recurrence of chest pain or chest discomfort. Careful assessment is recommended to differentiate between non-cardiac and cardiac causes. In the case of the latter, recurrent angina occurrence can be related to structural ('stretch pain', in-stent restenosis, in-stent thrombosis, incomplete revascularization, progression of coronary atherosclerosis) or functional (coronary micro-vascular dysfunction, epicardial coronary spasm) causes. Even though a complete diagnostic algorithm has not been validated, ECG exercise testing, stress imaging and invasive assessment of coronary blood flow and coronary vaso-motion (i.e. coronary flow reserve, provocation testing for coronary spasm) may be required. When repeated coronary revascularization is not indicated, therapeutic approaches should aim at targeting the underlying mechanism for the patient's symptoms using a variety of drugs currently available such as beta-blockers, calcium-channel blockers, ivabradine or ranolazine.
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Affiliation(s)
- Paolo Izzo
- Cardiology Department, Clinica ‘Villa Bianca’, Bari, Italy
| | - Andrea Macchi
- Cardiology Department, Busto Arsizio Hospital, (VA), Italy
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Non-invasive assessment of functionally relevant coronary artery stenoses with quantitative CT perfusion: preliminary clinical experiences. Eur Radiol 2011; 22:39-50. [DOI: 10.1007/s00330-011-2260-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 08/23/2011] [Accepted: 08/25/2011] [Indexed: 10/17/2022]
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Liga R, Marini C, Coceani M, Filidei E, Schlueter M, Bianchi M, Rossi G, Pardini S, Salvadori P, Parodi O, Rovai D, Sambuceti G, Marraccini P, Neglia D. Structural abnormalities of the coronary arterial wall--in addition to luminal narrowing--affect myocardial blood flow reserve. J Nucl Med 2011; 52:1704-12. [PMID: 21930670 DOI: 10.2967/jnumed.111.091009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Multislice CT provides information on coronary luminal narrowing and on the structural abnormalities of the coronary arterial wall using densitometric analysis. We sought to investigate the effects of coronary luminal narrowing, structural abnormalities of the coronary arterial wall, and cardiovascular risk factors on regional and global myocardial blood flow (MBF) reserve. METHODS We studied 68 patients (mean age ± SD, 61 ± 10 y; 41 men, 27 women) with an intermediate probability of coronary artery disease. We measured the severity of coronary stenoses and the fibroadipose, fibromuscular, and calcium components of the coronary arterial wall by 64-row multislice CT coronary angiography. We also measured regional and global MBF reserve by PET using (13)N-ammonia as a flow tracer at rest and after dipyridamole. RESULTS One or more significant coronary stenoses (≥50% luminal narrowing) was present in 32 patients (47%), and nonsignificant stenoses were present in 15 patients (22%). Regional MBF reserve was significantly different in the territories perfused by normal coronary arteries, nonsignificant coronary stenoses, and significant coronary stenoses (P < 0.001). Calcium content was higher in the coronary arteries with significant or nonsignificant stenoses (0.95% ± 1.08% and 0.73% ± 0.93%, respectively) than in those without stenoses (0.11% ± 0.38%, P < 0.001). Significant coronary stenosis (P = 0.047) and calcium content (P = 0.017) were the only independent determinants of impaired regional MBF reserve using multivariate analysis. At multiple logistic regression analysis, the Framingham risk score, an index of global cardiovascular risk burden, was the only significant determinant of global MBF reserve (P = 0.028). CONCLUSION Coronary stenoses and coronary calcium content independently affect regional MBF reserve. Framingham risk score is the only significant determinant of global MBF reserve.
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Sharif D, Sharif-Rasslan A, Shahla C, Khalil A, Rosenschein U. Coronary Flow Reserve of the Non-Ischemia Related Coronary Artery During Dobutamine Stress Echocardiography. Cardiol Res 2011; 2:174-180. [PMID: 28352387 PMCID: PMC5358225 DOI: 10.4021/cr57w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2011] [Indexed: 11/14/2022] Open
Abstract
Background Incorporation of analysis of coronary velocities in stress studies adds diagnostic value to both clinical variables and dobutamine echocardiography. Micorcirculatory abnormalities may precede obstructive corornary disease. Therefore the aim of this study was to assess Doppler derived coronary velocity and flow of the left anterior descending coronary artery (LAD) during dobutamine stress echocardiography (DSE) in patients without LAD-related ischemia. Methods Sixty nine patients with chest pain underwent DSE studies to evaluate myocardial ischemia. All had trans-thoracic Doppler interrogation of the distal LAD before and just after termination of the DSE. Coronary velocity reserves (CFR) were calculated as the ratios of post-DSE/baseline diastolic velocities. Volumetric flow in the distal LAD was calculated from the diameter of LAD color jet and velocity integral. Volumetric flow reserve was calculated as the ratio of post-DSE baseline LAD flows. Results At rest all subjects had left ventricular wall motion score index (WMSI) = 1, while in 28, wall motion abnormality appeared in non-LAD territory with WMSI = 1.17 ± 0.08. Peak diastolic velocity after DSE increased form 28.5 ± 13.6 to 52.4 ± 23.7 cm/sec, P = 9.5 × 10-11, and velocity-CFR was 2.08 ± 0.7. Diastolic LAD flow increased from 36.5 ± 23.8 to 75.75 ± 48.7 mL/min, P = 1.21 × 10-7 and volumetric-CFR was 2.6 ± 2.8. Peak diastolic velocity-CFR in patients without LV wall motion abnormality was 2.4 ± 0.7 while in those with motion abnormality 1.77 ± 0.56, P = 0.00008. Flow-derived LAD-CFR was 3.3 ± 3.7 in those without compared to 1.88 ± 0.57 in patients with wall motion abnormality, P < 0.05. Conclusion LAD velocity and flow reserves are reduced in patients with remote myocardial ischemia, which may indicate early atherosclerotic involvement.
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Affiliation(s)
- Dawod Sharif
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
| | | | - Camilia Shahla
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
| | - Amin Khalil
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
| | - Uri Rosenschein
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
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Gibson CM, Pinto D. Fractional flow reserve: a new set of lenses for the occulostenotic reflex? JACC Cardiovasc Interv 2011; 3:1282-3. [PMID: 21232722 DOI: 10.1016/j.jcin.2010.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 10/01/2010] [Indexed: 11/28/2022]
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Sert Kuniyoshi FH, Singh P, Gami AS, Garcia-Touchard A, van der Walt C, Pusalavidyasagar S, Wright RS, Vasquez EC, Lopez-Jimenez F, Somers VK. Patients with obstructive sleep apnea exhibit impaired endothelial function after myocardial infarction. Chest 2011; 140:62-67. [PMID: 21349927 DOI: 10.1378/chest.10-1722] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Impaired brachial flow-mediated dilation (FMD) is associated with risk for subsequent cardiovascular events in patients after myocardial infarction (MI). These patients often have obstructive sleep apnea (OSA). We tested the hypothesis that patients with OSA post MI will exhibit more severe impairment in FMD. METHODS We studied 64 patients with MI admitted to our hospital. OSA was determined using polysomnography. FMD was measured using high-resolution ultrasonography, with researchers blind to the OSA diagnosis. RESULTS The mean age was 60 ± 11 years, and the mean BMI was 29 (26, 32 kg/m(2)), 84% of patients were men, 39% had moderate to severe OSA (apnea-hypopnea index [AHI] > 15), and 31% of the patients had mild OSA (5 ≤ AHI < 15). FMD was severely impaired in patients with moderate to severe OSA (0.8% ± 0.7%) as compared with patients without OSA (4.7% ± 0.8%, P = .001) and with mild OSA (3.9% ± 0.8%, P = .015). Linear regression showed that FMD was associated with log nocturnal nadir oxygen saturation (minSaO(2)) (β = 31.17, P = .0001), age (β = -0.11, P = .006). MinSaO(2) was an independent predictor of FMD after adjustment for possible confounders (β = 26.15, P = .001). CONCLUSIONS FMD is severely impaired in patients with moderate to severe OSA post MI, which may be partially related to nocturnal hypoxemia. Patients with OSA may, therefore, be at higher risk for subsequent cardiovascular events after an MI. Identifying and treating OSA may have important implications in the long-term prognosis of patients post MI. Further studies are necessary to determine if the presence of OSA would affect the long-term occurrence of cardiovascular events after an MI.
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Affiliation(s)
- Fatima H Sert Kuniyoshi
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Prachi Singh
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Apoor S Gami
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Arturo Garcia-Touchard
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Christelle van der Walt
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Snigdha Pusalavidyasagar
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - R Scott Wright
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | | | - Francisco Lopez-Jimenez
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN
| | - Virend K Somers
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, MN.
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Yoshinaga K, Katoh C, Manabe O, Klein R, Naya M, Sakakibara M, Yamada S, deKemp RA, Tsutsui H, Tamaki N. Incremental Diagnostic Value of Regional Myocardial Blood Flow Quantification Over Relative Perfusion Imaging With Generator-Produced Rubidium-82 PET. Circ J 2011; 75:2628-34. [DOI: 10.1253/circj.cj-11-0502] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Chietsugu Katoh
- Health Sciences, Hokkaido University Graduate School of Medicine
| | - Osamu Manabe
- Nuclear Medicine, Hokkaido University Graduate School of Medicine
| | - Ran Klein
- Nuclear Medicine, Hokkaido University Graduate School of Medicine
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute
| | - Masanao Naya
- Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Mamoru Sakakibara
- Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Shiro Yamada
- Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Robert A. deKemp
- National Cardiac PET Centre, Division of Cardiology, University of Ottawa Heart Institute
| | - Hiroyuki Tsutsui
- Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Nagara Tamaki
- Nuclear Medicine, Hokkaido University Graduate School of Medicine
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Schindler TH, Schelbert HR, Quercioli A, Dilsizian V. Cardiac PET imaging for the detection and monitoring of coronary artery disease and microvascular health. JACC Cardiovasc Imaging 2010; 3:623-40. [PMID: 20541718 DOI: 10.1016/j.jcmg.2010.04.007] [Citation(s) in RCA: 278] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 04/21/2010] [Accepted: 04/26/2010] [Indexed: 12/11/2022]
Abstract
Positron emission tomography (PET) myocardial perfusion imaging in concert with tracer-kinetic modeling affords the assessment of regional myocardial blood flow (MBF) of the left ventricle in absolute terms (milliliters per gram per minute). Assessment of MBF both at rest and during various forms of vasomotor stress provides insight into early and subclinical abnormalities in coronary arterial vascular function and/or structure, noninvasively. The noninvasive evaluation and quantification of MBF and myocardial flow reserve (MFR) extend the scope of conventional myocardial perfusion imaging from detection of end-stage, advanced, and flow-limiting, epicardial coronary artery disease (CAD) to early stages of atherosclerosis or microvascular dysfunction. Recent studies have shown that impaired hyperemic MBF or MFR with PET, with or without accompanying CAD, is predictive of increased relative risk of death or progression of heart failure. Quantitative approaches that measure MBF with PET identify multivessel CAD and offer the opportunity to monitor responses to lifestyle and/or risk factor modification and to therapeutic interventions. Whether improvement or normalization of hyperemic MBF and/or the MFR will translate to improvement in long-term cardiovascular outcome remains clinically untested. In the meantime, absolute measures of MBF with PET can be used as a surrogate marker for coronary vascular health, and to monitor therapeutic interventions. Although the assessment of myocardial perfusion with PET has become an indispensable tool in cardiac research, it remains underutilized in clinical practice. Individualized, image-guided cardiovascular therapy may likely change this paradigm in the near future.
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Affiliation(s)
- Thomas H Schindler
- Nuclear Cardiology and Cardiac Imaging, Division of Cardiology, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland.
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Patel B, Fisher M. Therapeutic advances in myocardial microvascular resistance: Unravelling the enigma. Pharmacol Ther 2010; 127:131-47. [DOI: 10.1016/j.pharmthera.2010.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 04/28/2010] [Indexed: 02/02/2023]
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Pepine CJ, Anderson RD, Sharaf BL, Reis SE, Smith KM, Handberg EM, Johnson BD, Sopko G, Bairey Merz CN. Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women's Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 2010; 55:2825-32. [PMID: 20579539 PMCID: PMC2898523 DOI: 10.1016/j.jacc.2010.01.054] [Citation(s) in RCA: 570] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 01/13/2010] [Accepted: 01/18/2010] [Indexed: 12/18/2022]
Abstract
OBJECTIVES We investigated whether coronary microvascular dysfunction predicts major adverse outcomes during follow-up among women with signs and symptoms of ischemia. BACKGROUND Altered coronary reactivity occurs frequently in women evaluated for suspected ischemia, and the endothelium-dependent component is linked with adverse outcomes. Possible links between endothelium-independent microvascular coronary reactivity and adverse outcomes remain uncertain. METHODS As part of the National Heart, Lung and Blood Institute-sponsored WISE (Women's Ischemia Syndrome Evaluation), we investigated relationships between major adverse outcomes and baseline coronary flow reserve (CFR) after intracoronary adenosine in 189 women referred to evaluate suspected ischemia. RESULTS At a mean of 5.4 years, we observed significant associations between CFR and major adverse outcomes (death, nonfatal myocardial infarction, nonfatal stroke, or hospital stay for heart failure). An exploratory receiver-operator characteristic analysis identified CFR <2.32 as the best discriminating threshold for adverse outcomes (event rate 26.7%; and >or=2.32 event rate 12.2%; p = 0.01). Lower CFR was associated with increased risk for major adverse outcomes (hazard ratio: 1.16, 95% confidence interval: 1.04 to 1.30; p = 0.009). This held true among the 152 women without obstructive coronary artery disease (CAD) (hazard ratio: 1.20, 95% confidence interval: 1.05 to 1.38; p = 0.008). The CFR significantly improved prediction of adverse outcomes over angiographic CAD severity and other risk conditions. CONCLUSIONS Among women with suspected ischemia and atherosclerosis risk factors, coronary microvascular reactivity to adenosine significantly improves prediction of major adverse outcomes over angiographic CAD severity and CAD risk factors. These findings suggest that coronary microvessels represent novel targets for diagnostic and therapeutic strategies to predict and limit adverse outcomes in women. (Women's Ischemia Syndrome Evaluation [WISE]; NCT00000554).
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Affiliation(s)
- Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida 32610-0277, USA.
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OPREDELYaYuShchAYa ROL'VNUTRISOSUDISTOGO UL'TRAZVUKOVOGO ISSLEDOVANIYa DLYa VYBORATAKTIKI LEChENIYa BOL'NOGOS ZhELUDOChKOVOY TAKhIKARDIEY. КЛИНИЧЕСКАЯ ПРАКТИКА 2010. [DOI: 10.17816/clinpract119-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Karamitsos TD, Leccisotti L, Arnold JR, Recio-Mayoral A, Bhamra-Ariza P, Howells RK, Searle N, Robson MD, Rimoldi OE, Camici PG, Neubauer S, Selvanayagam JB. Relationship between regional myocardial oxygenation and perfusion in patients with coronary artery disease: insights from cardiovascular magnetic resonance and positron emission tomography. Circ Cardiovasc Imaging 2009; 3:32-40. [PMID: 19920032 DOI: 10.1161/circimaging.109.860148] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It is recognized that the interplay between myocardial ischemia, perfusion, and oxygenation in the setting of coronary artery disease (CAD) is complex and that myocardial oxygenation and perfusion may become dissociated. Blood oxygen level-dependent (BOLD) cardiovascular magnetic resonance (CMR) has the potential to noninvasively measure myocardial oxygenation, whereas positron emission tomography (PET) with oxygen-15 labeled water is the gold standard technique for myocardial blood flow quantification. Thus, we sought to apply BOLD CMR at 3 T and oxygen-15-labeled water PET in patients with CAD and normal volunteers to better understand the relationship between regional myocardial oxygenation and blood flow during vasodilator stress. METHODS AND RESULTS Twenty-two patients (age, 62+/-8 years; 16 men) with CAD (at least 1 stenosis > or =50% on quantitative coronary angiography) and 10 normal volunteers (age, 58+/-6 years; 6 men) underwent 3-T BOLD CMR and PET. For BOLD CMR, 4 to 6 midventricular short-axis images were acquired at rest and during adenosine stress (140 microg/kg/min). Using PET with oxygen-15-labeled water, myocardial blood flow was measured at baseline and during adenosine in the same slices. BOLD images were divided into 6 segments, and mean signal intensities calculated. Taking > or =50% stenosis on quantitative coronary angiography as the gold standard, cutoff values for stress myocardial blood flow (<2.45 mL/min/g; AUC, 0.83) and BOLD signal intensity change (<3.74%; AUC, 0.78) were determined to define ischemic segments. BOLD CMR and PET agreed on the presence or absence of ischemia in 18 of the 22 patients (82%) and in all normal subjects. On a per-segment analysis, 40% of myocardial segments with stress myocardial blood flow below the cutoff of 2.45 mL/min/g did not show deoxygenation, whereas 88% of segments with normal perfusion also had normal oxygenation measurements. CONCLUSIONS Regional myocardial perfusion and oxygenation may be dissociated, indicating that in patients with CAD, reduced perfusion does not always lead to deoxygenation.
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Affiliation(s)
- Theodoros D Karamitsos
- Department of Cardiovascular Medicine, Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford, United Kingdom
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Herzog BA, Husmann L, Valenta I, Gaemperli O, Siegrist PT, Tay FM, Burkhard N, Wyss CA, Kaufmann PA. Long-term prognostic value of 13N-ammonia myocardial perfusion positron emission tomography added value of coronary flow reserve. J Am Coll Cardiol 2009; 54:150-6. [PMID: 19573732 DOI: 10.1016/j.jacc.2009.02.069] [Citation(s) in RCA: 469] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 01/30/2009] [Accepted: 02/17/2009] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The goal of this study was to assess the predictive value of myocardial perfusion imaging with (13)N-ammonia positron emission tomography (PET) and coronary flow reserve (CFR) on long-term prognosis in patients with suspected myocardial ischemia. BACKGROUND No prognostic data exist on the predictive value of CFR and (13)N-ammonia PET. METHODS Perfusion and CFR were assessed in 256 patients using (13)N-ammonia PET, and follow-up was obtained in 245 (96%) patients. Sixteen early revascularized patients were excluded and 229 were assigned to normal versus abnormal perfusion or normal versus abnormal CFR (<2.0). Major adverse cardiac events (MACE) (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for cardiac reasons) were assessed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors for cardiac events. RESULTS During follow-up (5.4 +/- 2.2 years), 78 patients had at least 1 cardiac event, including 29 cardiac deaths. Abnormal perfusion (n = 126) was associated with a higher incidence of MACE (p < 0.001) and cardiac death (p < 0.05). In patients with normal perfusion, abnormal CFR was independently associated with a higher annual event rate over 3 years compared with normal CFR for MACE (1.4% vs. 6.3%; p < 0.05) and cardiac death (0.5% vs. 3.1%; p < 0.05). In abnormal perfusion, CFR remained predictive throughout the 10-year follow-up (p < 0.001). CONCLUSIONS Perfusion findings in (13)N-ammonia PET and CFR are strong outcome predictors. CFR allows further risk stratification, suggesting a "warranty" period of 3 years if normal CFR is associated with normal perfusion. Conversely, in patients with abnormal perfusion, an impaired CFR has added value for predicting adverse outcomes.
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Affiliation(s)
- Bernhard A Herzog
- Cardiac Imaging Section, University Hospital Zurich, Ramistrasse 100, Zurich, Switzerland
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Camici PG, Rimoldi OE. The Clinical Value of Myocardial Blood Flow Measurement. J Nucl Med 2009; 50:1076-87. [DOI: 10.2967/jnumed.108.054478] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Camici PG, Rimoldi OE. A Novel
18
F-Labeled Tracer for the Quantification of Myocardial Blood Flow and Infarct Size With Positron-Emission Tomography. Circ Cardiovasc Imaging 2009; 2:75-6. [DOI: 10.1161/circimaging.109.855791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paolo G. Camici
- From the Medical Research Council Clinical Sciences Centre (P.G.C., O.E.R.) and the National Heart and Lung Institute (P.G.C., O.E.R.), Imperial College, London, United Kingdom; and Consiglio Nazionale delle Ricerche (O.E.R.), Institute of Clinical Physiology, Pisa, Italy
| | - Ornella E. Rimoldi
- From the Medical Research Council Clinical Sciences Centre (P.G.C., O.E.R.) and the National Heart and Lung Institute (P.G.C., O.E.R.), Imperial College, London, United Kingdom; and Consiglio Nazionale delle Ricerche (O.E.R.), Institute of Clinical Physiology, Pisa, Italy
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Zehetgruber M, Mörtl D, Porenta G, Mundigler G, Christ G, Lengauer R, Stix G, Probst P, Maurer G, Sochor H, Siostrzonek P. Comparison of transesophageal Doppler coronary flow reserve measurements with thallium-201 single-photon emission computed tomography imaging in assessment of left anterior descending artery stenoses. Clin Cardiol 2009; 21:247-52. [PMID: 9562934 PMCID: PMC6655278 DOI: 10.1002/clc.4960210404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND HYPOTHESIS Recent studies demonstrate the feasibility of coronary flow reserve measurements by transesophageal echocardiographic (TEE) Doppler recordings of coronary sinus or left anterior descending (LAD) coronary artery flow velocity for detecting stenoses of the LAD artery. This study compares coronary flow reserve measurements by Doppler TEE with thallium-201 (201Tl) single-photon emission computed tomography (SPECT) in patients with proximal single-vessel LAD stenosis. METHODS Nineteen patients with various degrees of LAD stenosis (mean area stenosis 71 +/- 24%; range 24-96%) were studied. Area stenosis by quantitative coronary angiography was < 75% in 7 patients and > 75% in 12 patients. Transesophageal LAD and coronary sinus Doppler measurements were performed at baseline and after intravenous dipyridamole. Coronary flow reserve was calculated as the ratio of hyperemic to baseline average peak velocities. Predefined coronary flow reserve cut-off values of 1.8 for the coronary sinus method and of 2.0 for the LAD method were used for diagnosis of significant LAD stenosis. Results were compared with qualitative 201Tl dipyridamole SPECT. RESULTS Overall predictive accuracy for diagnosis of > 75% LAD stenosis was 79% for 201Tl SPECT, 77% for the transesophageal LAD and 79% for the transesophageal coronary sinus technique. Concordant results between 201Tl SPECT and the LAD and coronary sinus Doppler methods were observed in 79% and 71% of patients, respectively. CONCLUSIONS Thallium-201 SPECT and transesophageal Doppler assessment of coronary flow reserve have similar accuracy for diagnosing significant proximal LAD stenosis. Therefore, both transesophageal Doppler techniques might constitute another widely available, noninvasive method for assessment of left coronary artery disease, if disease location is proximal.
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Affiliation(s)
- M Zehetgruber
- Department od Cardiology, University od Vienna, Wahringer Gurtel 18-20, Vienna, Austria
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Gimelli A, Marzullo P, Landi P, L'Abbate A, Bottai M, Rovai D. Paucity of anginal symptoms and stress-induced perfusion abnormalities in ischemic cardiomyopathy. J Nucl Cardiol 2008; 15:680-6. [PMID: 18761271 DOI: 10.1016/j.nuclcard.2008.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 05/22/2008] [Indexed: 11/13/2022]
Abstract
BACKGROUND We sought to investigate whether the paucity of anginal symptoms in patients with ischemic cardiomyopathy reflects a reduction in the severity of stress-induced myocardial ischemia. METHODS AND RESULTS We selected 38 patients with coronary artery disease and severe left ventricular dysfunction (ejection fraction [EF] <or=25%) (group 1), who underwent stress gated single photon emission computed tomography. In parallel, we selected 2 groups of 38 patients with coronary artery disease and EF between 26% and 45% (group 2) or EF greater than 45% (group 3), matched to group 1 patients. Effort angina was less frequent in group 1 (29%) than in group 2 (50%) and group 3 (82%) (P = .023). Stress-induced perfusion abnormalities, identified by the summed difference score (SDS), were less extensive in group 1 (mean SDS, 3 +/- 3) than in group 2 (mean SDS, 6 +/- 5) and group 3 (mean SDS, 8 +/- 4) (P = .019), whereas perfusion abnormalities at rest (summed rest score [SRS]) were more extensive in group 1 (mean SRS, 12 +/- 4) than in group 2 (mean SRS, 6 +/- 3) and group 3 (mean SRS, 3 +/- 2) (P = .015). CONCLUSION The paucity of anginal symptoms in ischemic cardiomyopathy reflects a limited extent of stress-induced myocardial ischemia and a higher extent of necrosis.
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Rahimtoola SH, Dilsizian V, Kramer CM, Marwick TH, Vanoverschelde JLJ. Chronic ischemic left ventricular dysfunction: from pathophysiology to imaging and its integration into clinical practice. JACC Cardiovasc Imaging 2008; 1:536-55. [PMID: 19356479 PMCID: PMC2664223 DOI: 10.1016/j.jcmg.2008.05.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Accepted: 05/19/2008] [Indexed: 10/21/2022]
Abstract
Chronic ischemic left ventricular dysfunction is present in a number of clinical syndromes in which myocardial revascularization results in an improvement of left ventricular function, patients' functional class, and their survival. Early diagnosis of and treatment of viability is essential. Coronary arteriography is of limited value in diagnosis of viability. Noninvasive testing is essential for diagnosis, which can be matched to the pathophysiologic changes that occur in hibernating myocardium. However, no single test has a perfect, or near perfect, sensitivity and specificity, and thus, a combination of tests are usually needed. Algorithms are developed to integrate these tests in clinical decision making.
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Affiliation(s)
- Shahbudin H Rahimtoola
- Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California 90033, USA.
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