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Kwiecinski J, Tzolos E, Williams MC, Dey D, Berman D, Slomka P, Newby DE, Dweck MR. Noninvasive Coronary Atherosclerotic Plaque Imaging. JACC Cardiovasc Imaging 2023; 16:1608-1622. [PMID: 38056987 DOI: 10.1016/j.jcmg.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/06/2023] [Accepted: 08/16/2023] [Indexed: 12/08/2023]
Abstract
Coronary artery disease is the leading cause of morbidity and mortality worldwide. Despite remarkable advances in the management of coronary artery disease, the prediction of adverse coronary events remains challenging. Over the preceding decades, considerable effort has been made to improve risk stratification using noninvasive imaging. Recently, these efforts have increasingly focused on the direct imaging of coronary atherosclerotic plaque. Modern imaging now allows imaging of coronary plaque burden, plaque type, atherosclerotic plaque activity, and plaque thrombosis, which have major potential to refine patient risk stratification, aid decision making, and advance future clinical practice.
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Affiliation(s)
- Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Evangelos Tzolos
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Damini Dey
- Division of Artificial Intelligence, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel Berman
- Division of Artificial Intelligence, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Piotr Slomka
- Division of Artificial Intelligence, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA; Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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2
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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3
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 226] [Impact Index Per Article: 226.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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4
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Gaibazzi N, Tuttolomondo D, Guaricci AI, De Marco F, Pontone G. Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide. J Cardiovasc Med (Hagerstown) 2022; 23:12-21. [PMID: 34366402 DOI: 10.2459/jcm.0000000000001235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened. The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.
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Affiliation(s)
| | | | | | - Federico De Marco
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese
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5
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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6
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Khemka A, Sutter DA, Habhab MN, Thomaides A, Hornsby K, Feigenbaum H, Sawada SG. Prognostic value of left atrial size in hypertensive African Americans undergoing stress echocardiography. World J Cardiol 2021; 13:733-744. [PMID: 35070115 PMCID: PMC8716971 DOI: 10.4330/wjc.v13.i12.733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/01/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Left atrial (LA) enlargement is a marker of increased risk in the general population undergoing stress echocardiography. African American (AA) patients with hypertension are known to have less atrial remodeling than whites with hypertension. The prognostic impact of LA enlargement in AA with hypertension undergoing stress echocardiography is uncertain.
AIM To investigate the prognostic value of LA size in hypertensive AA patients undergoing stress echocardiography.
METHODS This retrospective outcomes study enrolled 583 consecutive hypertensive AA patients who underwent stress echocardiography over a 2.5-year period. Clinical characteristics including cardiovascular risk factors, stress and echocardiographic data were collected from the electronic health record of a large community hospital. Treadmill exercise and Dobutamine protocols were conducted based on standard practices. Patients were followed for all-cause mortality. The optimal cutoff value of antero-posterior LA diameter for mortality was assessed by receiver operating characteristic analysis. Cox regression was used to determine variables associated with outcome.
RESULTS The mean age was 57 ± 12 years. LA dilatation was present in 9% (54) of patients (LA anteroposterior ≥ 2.4 cm/m2). There were 85 deaths (15%) during 4.5 ± 1.7 years of follow-up. LA diameter indexed for body surface area had an area under the curve of 0.72 ± 0.03 (optimal cut-point of 2.05 cm/m2). Variables independently associated with mortality included age [P = 0.004, hazard ratio (HR) 1.34 (1.10-1.64)], tobacco use [P = 0.001, HR 2.59 (1.51-4.44)], left ventricular hypertrophy [P = 0.001 , HR 2.14 (1.35-3.39)], Dobutamine stress [P = 0.003, HR 2.12 (1.29-3.47)], heart failure history [P = 0.031, HR 1.76 (1.05-2.94)], LA diameter ≥ 2.05 cm/m2 [P = 0.027, HR 1.73 (1.06-2.82)], and an abnormal stress echocardiogram [P = 0.033, HR 1.67 (1.04-2.68)]. LA diameter as a continuous variable was also independently associated with mortality but LA size ≥ 2.40 cm/m2 was not.
CONCLUSION LA enlargement is infrequent in hypertensive AA patients when traditional reference values are used. LA enlargement is independently associated with mortality when a lower than “normal” threshold (≥ 2.05 cm/m2) is used.
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Affiliation(s)
- Abhishek Khemka
- Department of Medicine, Division of Cardiology, Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN 46202, United States
| | - David A Sutter
- Department of Cardiology, Michigan Heart, Ann Arbor, MI 48197, United States
| | - Mazin N Habhab
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | | | - Kyle Hornsby
- Department of Cardiology, Indiana University Health, Bloomington, IN 47403, United States
| | - Harvey Feigenbaum
- Department of Medicine, Division of Cardiology, Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN 46202, United States
| | - Stephen G Sawada
- Department of Medicine, Division of Cardiology, Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN 46202, United States
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 106.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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8
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 161] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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9
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Reynolds HR, Shaw LJ, Min JK, Page CB, Berman DS, Chaitman BR, Picard MH, Kwong RY, O’Brien SM, Huang Z, Mark DB, Nath RK, Dwivedi SK, Smanio PEP, Stone PH, Held C, Keltai M, Bangalore S, Newman JD, Spertus JA, Stone GW, Maron DJ, Hochman JS. Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity. Circulation 2021; 144:1024-1038. [PMID: 34496632 PMCID: PMC8478888 DOI: 10.1161/circulationaha.120.049755] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/16/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy. METHODS In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory-interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). RESULTS Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61-1.30]; severe ischemia HR, 0.83 [95% CI, 0.57-1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86-1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98-1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06-6.98]) and MI (HR, 3.78 [95% CI, 1.63-8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%-12.4%]), but 4-year all-cause mortality was similar. CONCLUSIONS Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01471522.
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Affiliation(s)
| | - Leslee J. Shaw
- Weill Cornell Medicine / New York Presbyterian Hospital, New York, NY, USA
| | | | | | | | - Bernard R. Chaitman
- St Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis, Missouri, USA
| | - Michael H. Picard
- Massachusetts General Hospital and Harvard Medical School, Massachusetts, USA
| | | | - Sean M. O’Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Zhen Huang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel B. Mark
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Paola E. P. Smanio
- Instituto Dante Pazzanese de Cardiologia e Fleury Medicina e Saúde, São Paulo, Brazil
| | - Peter H. Stone
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Claes Held
- Dept of Medical Sciences, Cardiology, Uppsala University and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | | | | | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/Univeristy of Missouri - Kansas City (UMKC)
| | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, NY, USA
| | - David J. Maron
- Department of Medicine, Stanford University, Stanford, CA, USA
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Kardos A, Senior R, Becher H. Commentary: Vasodilator Myocardial Perfusion Cardiac Magnetic Resonance Imaging Is Superior to Dobutamine Stress Echocardiography in the Detection of Relevant Coronary Artery Stenosis: A Systematic Review and Meta-Analysis on Their Diagnostic Accuracy. Front Cardiovasc Med 2021; 8:694323. [PMID: 34179149 PMCID: PMC8222596 DOI: 10.3389/fcvm.2021.694323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital, Milton Keynes, United Kingdom.,School of Sciences and Medicine, University of Buckingham, Buckingham, United Kingdom
| | - Roxy Senior
- Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Harald Becher
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, AB, Canada
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11
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Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome. J Clin Med 2021; 10:jcm10040610. [PMID: 33562869 PMCID: PMC7914537 DOI: 10.3390/jcm10040610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 01/09/2023] Open
Abstract
Ischemic heart disease (IHD) persists as the leading cause of death in the Western world. In recent decades, great headway has been made in reducing mortality due to IHD, based around secondary prevention. The advent of coronary revascularization techniques, first coronary artery bypass grafting (CABG) surgery in the 1960s and then percutaneous coronary intervention (PCI) in the 1970s, has represented one of the major breakthroughs in medicine during the last century. The benefit provided by these techniques, especially PCI, has been crucial in lowering mortality rates in acute coronary syndrome (ACS). However, in the setting where IHD is most prevalent, namely chronic coronary syndrome (CCS), the increase in life expectancy provided by coronary revascularization is controversial. Over more than 40 years, several clinical trials have been carried out comparing optimal medical treatment (OMT) alone with a strategy of routine coronary revascularization on top of OMT. Beyond a certain degree of symptomatic improvement and lower incidence of minor events, routine invasive management has not demonstrated a convincing effect in terms of reducing mortality in CCS. Based on the accumulated evidence more than half a century after the first revascularization procedures were used, invasive management should be considered in those patients with uncontrolled symptoms despite OMT or high-risk features related to left ventricular function, coronary anatomy, or functional assessment, taking into account the patient expectations and preferences.
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12
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Batlle JC, Kirsch J, Bolen MA, Bandettini WP, Brown RKJ, Francois CJ, Galizia MS, Hanneman K, Inacio JR, Johnson TV, Khosa F, Krishnamurthy R, Rajiah P, Singh SP, Tomaszewski CA, Villines TC, Wann S, Young PM, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome. J Am Coll Radiol 2020; 17:S55-S69. [PMID: 32370978 DOI: 10.1016/j.jacr.2020.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/17/2022]
Abstract
Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Juan C Batlle
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida.
| | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | | | - W Patricia Bandettini
- National Institutes of Health, Bethesda, Maryland; Society for Cardiovascular Magnetic Resonance
| | | | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joao R Inacio
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology Expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear Cardiology Expert
| | | | | | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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13
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Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Alexander KP, Senior R, Boden WE, Stone GW, Goodman SG, Lopes RD, Lopez-Sendon J, White HD, Maggioni AP, Shaw LJ, Min JK, Picard MH, Berman DS, Chaitman BR, Mark DB, Spertus JA, Cyr DD, Bhargava B, Ruzyllo W, Wander GS, Chernyavskiy AM, Rosenberg YD, Maron DJ. Baseline Characteristics and Risk Profiles of Participants in the ISCHEMIA Randomized Clinical Trial. JAMA Cardiol 2020; 4:273-286. [PMID: 30810700 DOI: 10.1001/jamacardio.2019.0014] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance It is unknown whether coronary revascularization, when added to optimal medical therapy, improves prognosis in patients with stable ischemic heart disease (SIHD) at increased risk of cardiovascular events owing to moderate or severe ischemia. Objective To describe baseline characteristics of participants enrolled and randomized in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate whether qualification by stress imaging or nonimaging exercise tolerance test (ETT) influenced risk profiles. Design, Setting, and Participants The ISCHEMIA trial recruited patients with SIHD with moderate or severe ischemia on stress testing. Blinded coronary computed tomography angiography was performed in most participants and reviewed by a core laboratory to exclude left main stenosis of at least 50% or no obstructive coronary artery disease (CAD) (<50% for imaging stress test and <70% for ETT). The study included 341 enrolling sites (320 randomizing) in 38 countries and patients with SIHD and moderate or severe ischemia on stress testing. Data presented were extracted on December 17, 2018. Main Outcomes and Measures Enrolled, excluded, and randomized participants' baseline characteristics. No clinical outcomes are reported. Results A total of 8518 patients were enrolled, and 5179 were randomized. Common reasons for exclusion were core laboratory determination of insufficient ischemia, unprotected left main stenosis of at least 50%, or no stenosis that met study obstructive CAD criteria on study coronary computed tomography angiography. Randomized participants had a median age of 64 years, with 1168 women (22.6%), 1726 nonwhite participants (33.7%), 748 Hispanic participants (15.5%), 2122 with diabetes (41.0%), and 4643 with a history of angina (89.7%). Among the 3909 participants randomized after stress imaging, core laboratory assessment of ischemia severity (in 3901 participants) was severe in 1748 (44.8%), moderate in 1600 (41.0%), mild in 317 (8.1%) and none or uninterpretable in 236 (6.0%), Among the 1270 participants who were randomized after nonimaging ETT, core laboratory determination of ischemia severity (in 1266 participants) was severe (an eligibility criterion) in 1051 (83.0%), moderate in 101 (8.0%), mild in 34 (2.7%) and none or uninterpretable in 80 (6.3%). Among the 3912 of 5179 randomized participants who underwent coronary computed tomography angiography, 79.0% had multivessel CAD (n = 2679 of 3390) and 86.8% had left anterior descending (LAD) stenosis (n = 3190 of 3677) (proximal in 46.8% [n = 1749 of 3739]). Participants undergoing ETT had greater frequency of 3-vessel CAD, LAD, and proximal LAD stenosis than participants undergoing stress imaging. Conclusions and Relevance The ISCHEMIA trial randomized an SIHD population with moderate or severe ischemia on stress testing, of whom most had multivessel CAD. Trial Registration ClinicalTrials.gov Identifier: NCT01471522.
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Affiliation(s)
- Judith S Hochman
- Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York
| | - Sripal Bangalore
- Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Roxy Senior
- Royal Brompton Hospital, London, United Kingdom.,Northwick Park Hospital, London, United Kingdom
| | - William E Boden
- VA New England Healthcare System Boston, Boston, Massachusetts
| | - Gregg W Stone
- Columbia University Medical Center, New York, New York.,Cardiovascular Research Foundation, New York, New York
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jose Lopez-Sendon
- Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz, Madrid, Spain
| | - Harvey D White
- Green Lane Cardiovascular Services, Auckland Hospital, Auckland, New Zealand
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy
| | | | - James K Min
- Weill Cornell Medicine, New York, New York.,New York-Presbyterian Hospital, New York, New York
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Daniel B Mark
- Duke University Medical Center, Durham, North Carolina
| | - John A Spertus
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Derek D Cyr
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Balram Bhargava
- All India Institutes of Medical Sciences, New Delhi, Delhi, India
| | - Witold Ruzyllo
- The Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland
| | | | - Alexander M Chernyavskiy
- E. Meshalkin National Medical Research Center, Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | | | - David J Maron
- Stanford University School of Medicine, Stanford, California
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Shaw LJ, Reynolds HR, Picard MH. A Leap Forward for Ischemia-Guided Revascularization: Stress Echocardiography Predicts Angina Benefit With Percutaneous Coronary Intervention. Circulation 2019; 140:1981-1983. [PMID: 31707830 DOI: 10.1161/circulationaha.119.044026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | | | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston (M.H.P.)
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15
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Barbieri A, Mantovani F, Bursi F, Bartolacelli Y, Manicardi M, Lauria MG, Boriani G. 12-year Temporal Trend in Referral Pattern and Test Results of Stress Echocardiography in a Tertiary Care Referral Center with Moderate Volume Activities and Cath-lab Facility. J Cardiovasc Echogr 2018; 28:32-38. [PMID: 29629257 PMCID: PMC5875133 DOI: 10.4103/jcecho.jcecho_48_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Data on stress echocardiography (SE) time-related changes in referral patterns and diagnostic yield for detection of inducible ischemia could enhance Echo Lab quality benchmarks and performance measures. Aim This study aims to evaluate temporal trends in SE test results among ambulatory patients with suspected or known coronary artery disease (CAD) in a tertiary care referral center with moderate (>100/year) volume SE activities and Cath-Lab facility. Methods From January 2004 to December 2015, 1954 patients (mean age 62 ± 12 years, 42% women, 27% with known CAD) underwent SE (1673 exercise SE, 86%, 246 pharmacological SE, 12%, 35 pacing SE, 2%). Time was grouped into three 4 year periods, where clinical data and test results were evaluated. Results Our series comprised low-to-intermediate pretest probability of CAD throughout the observation period (overall pretest probability of CAD 19% ± 15%). A progressive decline over time in the rate of pharmacological SE instead of a dramatic increment of exercise SE (79%-96%, P < 0.0001) was noted. The use of beta-blockers increased (from 43% to 66%, P < 0.0001), while the use of nitrates decreased (from 11% to 4%, P < 0.0001) over time. We noted a very uncommon occurrence of abnormal test results with a further decrease in the last period (from 11% to 3%, P < 0.0001). Conclusions We observed, over a 12-year period, a progressive decrease in the frequency of inducible myocardial ischemia among patients with known or suspected CADe referred to our Echo Lab for SE with Cath-Lab facility, and this trend was parallel to changes in SE referral practice. These findings are particularly relevant if we consider the practical implications on diagnostic SE accuracy and risk assessment.
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Affiliation(s)
- Andrea Barbieri
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Mantovani
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Bursi
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Ylenia Bartolacelli
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Manicardi
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Giulia Lauria
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Boriani
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
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16
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Boiten HJ, Ekmen H, Zijlstra F, van Domburg RT, Schinkel AF. Impact of Early Coronary Revascularization on Long-Term Outcomes in Patients With Myocardial Ischemia on Dobutamine Stress Echocardiography. Am J Cardiol 2016; 118:635-40. [PMID: 27394410 DOI: 10.1016/j.amjcard.2016.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/03/2016] [Accepted: 06/03/2016] [Indexed: 01/09/2023]
Abstract
The role of early coronary revascularization in the management of stable coronary artery disease remains controversial. The aim of this study was to evaluate the impact of early coronary revascularization on long-term outcomes (>10 years) after an ischemic dobutamine stress echocardiography (DSE) in patients with known or suspected coronary artery disease. Patients without stress-induced ischemia on DSE and those who underwent late coronary revascularization (>90 days after DSE) were excluded. The final study cohort consisted of 905 patients. A DSE with a peak wall motion score index of 1.1 to 1.7 was considered mild to moderately abnormal (n = 460), and >1.7 was markedly abnormal (n = 445). End points were all-cause and cardiac mortality. The impact of early coronary revascularization on outcomes was assessed using Kaplan-Meier survival analysis and Cox's proportional hazard regression models. Early coronary revascularization was performed in 222 patients (percutaneous coronary intervention in 113 [51%] and coronary artery bypass grafting in 109 patients [49%]). During a median follow-up time of 10 years (range 8 to 15), 474 deaths (52%) occurred, of which were 241 (51%) due to cardiac causes. Kaplan-Meier survival curves showed that both in patients with a markedly abnormal DSE and a mild-to-moderately abnormal DSE, early revascularization was associated with better long-term outcomes. Multivariable analyses revealed that early revascularization had a beneficial effect on all-cause mortality (hazard ratio 0.60, 95% confidence interval 0.46 to 0.79) and cardiac mortality (hazard ratio 0.49, 95% confidence interval 0.34 to 0.72). In conclusion, early coronary revascularization has a beneficial impact on long-term outcomes in patients with myocardial ischemia on DSE. Early coronary revascularization was associated with better outcomes not only in patients with a markedly abnormal DSE but also in those with a mild to moderately abnormal DSE.
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17
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Argulian E, Chaudhry FA. Evaluating left ventricular systolic dysfunction: Stress echocardiography. J Nucl Cardiol 2015; 22:957-60. [PMID: 26153256 DOI: 10.1007/s12350-015-0116-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 02/01/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Edgar Argulian
- Mount Sinai St Luke's Hospital, 1111 Amsterdam Ave, New York, NY, USA.
| | - Farooq A Chaudhry
- Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, USA.
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18
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Yao SS, Supariwala A, Yao A, Dukkipati SS, Wyne J, Chaudhry FA. Prognostic Value of Stress Echocardiography in Patients With Low-Intermediate or High Short-Term (10 Years) Versus Low (<39%) or High (≥39%) Lifetime Predicted Risk of Cardiovascular Disease According to the American College of Cardiology/American Heart Association 2013 Cardiovascular Risk Calculator. Am J Cardiol 2015; 116:725-9. [PMID: 26138377 DOI: 10.1016/j.amjcard.2015.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 11/27/2022]
Abstract
This study evaluates the prognostic value of stress echocardiography (Secho) in short-term (10 years) and lifetime atherosclerotic cardiovascular disease risk-defined groups according to the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator. The ideal risk assessment and management of patients with low-to-intermediate or high short-term versus low (<39%) or high (≥39%) lifetime CV risk is unclear. The purpose of this study was to evaluate the prognostic value of Secho in short-term and lifetime CV risk-defined groups. We evaluated 4,566 patients (60 ± 13 years; 46% men) who underwent Secho (41% treadmill and 59% dobutamine) with low-intermediate short-term (<20%) risk divided into low (<39%, n = 368) or high (≥39%, n = 661) lifetime CV risk and third group with high short-term risk (≥20%, n = 3,537). Follow-up (3.2 ± 1.5 years) for nonfatal myocardial infarction (n = 102) and cardiac death (n = 140) were obtained. By univariate analysis, age (p <0.001) and ≥3 new ischemic wall motion abnormalities (WMAs, p <0.001) were significant predictors of cardiac events. Cumulative survival in patients was significantly worse in patients with ≥3 WMA versus <3 WMA in low-intermediate short-term and low (3.3% vs 0.3% per year, p <0.001) or high (2.0% vs 0% per year, p <0.001) lifetime risk and also in those with high short-term CV risk group (3.5% vs 1.0% per year, p <0.001). Multivariate Cox proportional hazards analysis identified ≥3 new ischemic WMAs as the strongest predictor of cardiac events (hazard ratio 3.0, 95% confidence interval 2.3 to 3.9, p <0.001). In conclusion, Secho results (absence or presence of ≥3 new ischemic segments) can further refine risk assessment in patients with low-intermediate or high short-term versus low or high lifetime cardiovascular risk. Event rate with normal Secho is low (≤1% per year) but higher in patients with high short-term CV risk by the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator.
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19
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Agarwal V, Yao SS, Chaudhry FA. Utilization of stress echocardiography in patients with multivessel coronary artery disease. J Cardiovasc Med (Hagerstown) 2015; 17:354-60. [PMID: 26258724 DOI: 10.2459/jcm.0000000000000298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the role of stress echocardiography in the risk stratification and prognosis of patients with multivessel coronary artery disease (CAD). BACKGROUND Stress echocardiography is an established technique for diagnosis, risk stratification, and prognosis of patients with known or suspected CAD. METHODS We evaluated 409 patients (65 ± 10 years; 63% men) referred for stress echocardiography (45% treadmill, 55% dobutamine), who underwent stress echocardiography and coronary angiography within 3 months. All patients had multivessel CAD as defined by coronary stenosis (≥50% left main or ≥70% in two or more major epicardial vessels or branches). The left ventricle was divided into 16 segments and was scored on a five-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of ≥1 grade). RESULTS Follow-up (3.1 ± 1.3 years) for nonfatal myocardial infarction (n = 35) and cardiac death (n = 25) was obtained. In patients with multivessel CAD, stress echocardiography effectively risk-stratified normal (no ischemia, n = 83) vs. abnormal (ischemia, n = 326) groups for cardiac events (event rate 1.9 vs. 5.4%/year; P < 0.01). Multivariable Cox proportional-hazards regression model identified stress-induced ischemia (hazard ratio 5.5, 95% confidence interval 1.9-15.9, P = 0.002) as the most significant predictor of adverse cardiac events. A stepwise Cox proportional-hazards model demonstrated significant incremental prognostic value of stress echocardiography over clinical variables, stress electrocardiography and resting left ventricular function (P < 0.0001), with the highest global chi-square value. CONCLUSIONS In patients with angiographically significant multivessel CAD, despite normal-stress echocardiography, there was an intermediate cardiac event rate (1.9%/year); abnormal-stress echocardiography identified a high-risk group (5.4%/year); and stress echocardiography provided incremental prognostic value for risk stratification and prediction of cardiac events.
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Affiliation(s)
- Vikram Agarwal
- aMount Sinai Health System, New York bValley Health System, Ridgewood, New Jersey, USA
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20
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Reynolds HR, Picard MH, Hochman JS. Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease does not effectively identify revascularization candidates. Circ Cardiovasc Imaging 2015; 8:discussion p 9. [PMID: 25977302 DOI: 10.1161/circimaging.113.000362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Harmony R Reynolds
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.).
| | - Michael H Picard
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.)
| | - Judith S Hochman
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.)
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21
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Shaw LJ, Berman DS, Picard MH, Friedrich MG, Kwong RY, Stone GW, Senior R, Min JK, Hachamovitch R, Scherrer-Crosbie M, Mieres JH, Marwick TH, Phillips LM, Chaudhry FA, Pellikka PA, Slomka P, Arai AE, Iskandrian AE, Bateman TM, Heller GV, Miller TD, Nagel E, Goyal A, Borges-Neto S, Boden WE, Reynolds HR, Hochman JS, Maron DJ, Douglas PS. Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging. JACC Cardiovasc Imaging 2015; 7:593-604. [PMID: 24925328 DOI: 10.1016/j.jcmg.2013.10.021] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 10/01/2013] [Accepted: 10/01/2013] [Indexed: 12/25/2022]
Abstract
The lack of standardized reporting of the magnitude of ischemia on noninvasive imaging contributes to variability in translating the severity of ischemia across stress imaging modalities. We identified the risk of coronary artery disease (CAD) death or myocardial infarction (MI) associated with ≥10% ischemic myocardium on stress nuclear imaging as the risk threshold for stress echocardiography and cardiac magnetic resonance. A narrative review revealed that ≥10% ischemic myocardium on stress nuclear imaging was associated with a median rate of CAD death or MI of 4.9%/year (interquartile range: 3.75% to 5.3%). For stress echocardiography, ≥3 newly dysfunctional segments portend a median rate of CAD death or MI of 4.5%/year (interquartile range: 3.8% to 5.9%). Although imprecisely delineated, moderate-severe ischemia on cardiac magnetic resonance may be indicated by ≥4 of 32 stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments. Risk-based thresholds can define equivalent amounts of ischemia across the stress imaging modalities, which will help to translate a common understanding of patient risk on which to guide subsequent management decisions.
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Affiliation(s)
- Leslee J Shaw
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, Georgia.
| | - Daniel S Berman
- Department of Medicine, Division of Cardiac Imaging/Nuclear Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael H Picard
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthias G Friedrich
- Department of Medicine, Division of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Raymond Y Kwong
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregg W Stone
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Roxy Senior
- Department of Cardiovascular Medicine, Division of Cardiology, Imperial College London, London, United Kingdom
| | - James K Min
- Department of Cardiovascular Medicine, Division of Radiology, Weill Cornell Medical College, New York, New York
| | - Rory Hachamovitch
- Department of Cardiovascular Medicine, Division of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Marielle Scherrer-Crosbie
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer H Mieres
- Department of Medicine, Division of Cardiology, North Shore Long Island Jewish Hospital, Manhasset, New York
| | - Thomas H Marwick
- Department of Medicine, Division of Cardiology, Menzies Research Institute of Tasmania, Hobart, Australia
| | - Lawrence M Phillips
- Department of Medicine, Division of Cardiology, New York University Medical Center, New York, New York
| | - Farooq A Chaudhry
- Department of Medicine, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patricia A Pellikka
- Department of Medicine, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Piotr Slomka
- Department of Medicine, Division of Imaging, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew E Arai
- Department of Medicine, Division of Cardiovascular Medicine, National Institutes of Health/National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Ami E Iskandrian
- Department of Radiology, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy M Bateman
- Department of Medicine, Division of Cardiology, St. Luke's Mid-America Heart Institute, Kansas City, Missouri
| | | | - Todd D Miller
- Department of Medicine, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Eike Nagel
- Department of Medicine, Division of Cardiovascular Medicine, King's College London, London, United Kingdom
| | - Abhinav Goyal
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, Georgia
| | - Salvador Borges-Neto
- Department of Nuclear Medicine, Division of Radiology, Duke Clinical Research Institute, Durham, North Carolina
| | - William E Boden
- Department of Medicine, Division of Cardiology, Samuel S. Stratton VA Medical Center, Albany, New York
| | - Harmony R Reynolds
- Department of Medicine, Division of Cardiology, New York University Medical Center, New York, New York
| | - Judith S Hochman
- Department of Medicine, Division of Cardiology, New York University Medical Center, New York, New York
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Pamela S Douglas
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
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Argulian E, Agarwal V, Bangalore S, Chatterjee S, Makani H, Rozanski A, Chaudhry FA. Meta-analysis of prognostic implications of dyspnea versus chest pain in patients referred for stress testing. Am J Cardiol 2014; 113:559-64. [PMID: 24315110 DOI: 10.1016/j.amjcard.2013.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/20/2013] [Accepted: 10/20/2013] [Indexed: 11/19/2022]
Abstract
Previous studies have suggested that patients with dyspnea referred for stress testing have high mortality. However, it is not clear whether this is explained by high rates of ischemia. The aim of the present study was to evaluate the incidence of ischemia in patients with dyspnea compared with patients with chest pain referred for stress testing and assess the outcomes of such patients. We systematically searched the electronic databases, MEDLINE, PubMed, EMBASE, and the Cochrane Library, until December 2012 to identify studies of patients with known or suspected coronary artery disease undergoing stress testing. We extracted data on group-specific incidence of stress-induced ischemia and all-cause mortality. In our analyses, we identified and included 6 studies that evaluated a total of 5,753 patients with dyspnea and 24,491 patients with chest pain as the clinical indication for stress testing. There was no statistically significant difference in the incidence of ischemia on stress imaging in patients with dyspnea compared with patients with chest pain (37.4% vs 30.2%, odds ratio 1.43, 95% confidence interval 0.99 to 2.06, p = 0.06). However, during the follow-up period, patients with dyspnea had higher all-cause mortality rates compared with patients with chest pain (annual mortality 4.9% vs 2.3%), with odds ratio of 2.57 (95% confidence interval 1.75 to 3.76, p <0.001). In conclusion, in patients undergoing stress testing, those evaluated for dyspnea had a significant increase in all-cause mortality but did not have higher rates of ischemia compared with patients presenting with chest pain. Clinicians evaluating patients with self-reported dyspnea should be aware that these patients represent a high-risk group with increased risk of mortality.
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Affiliation(s)
- Edgar Argulian
- Division of Cardiology, Department of Medicine, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Vikram Agarwal
- Division of Cardiology, Department of Medicine, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York.
| | | | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Harikrishna Makani
- Division of Cardiology, Department of Medicine, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Alan Rozanski
- Division of Cardiology, Department of Medicine, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Farooq A Chaudhry
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart Network, New York, New York
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Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Paul Taggart D, van der Wall EE, Vrints CJ, Luis Zamorano J, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Anton Sirnes P, Luis Tamargo J, Tendera M, Torbicki A, Wijns W, Windecker S, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, González-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Dalby Kristensen S, Lancellotti P, Pietro Maggioni A, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Anton Sirnes P, Gabriel Steg P, Timmis A, Wijns W, Windecker S, Yildirir A, Luis Zamorano J. Guía de Práctica Clínica de la ESC 2013 sobre diagnóstico y tratamiento de la cardiopatía isquémica estable. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJM, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J 2013; 34:2949-3003. [PMID: 23996286 DOI: 10.1093/eurheartj/eht296] [Citation(s) in RCA: 2906] [Impact Index Per Article: 264.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
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- The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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Argulian E, Halpern DG, Agarwal V, Agarwal SK, Chaudhry FA. Predictors of Ischemia in Patients Referred for Evaluation of Exertional Dyspnea: A Stress Echocardiography Study. J Am Soc Echocardiogr 2013; 26:72-6. [DOI: 10.1016/j.echo.2012.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Indexed: 11/26/2022]
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Tanaka H, Chikamori T, Hida S, Igarashi Y, Shiba C, Usui Y, Hatano T, Yamashina A. Relationship of SYNTAX Score to Myocardial Ischemia as Assessed on Myocardial Perfusion Imaging. Circ J 2013; 77:2772-7. [DOI: 10.1253/circj.cj-13-0099] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Satoshi Hida
- Department of Cardiology, Tokyo Medical University
| | | | - Chie Shiba
- Department of Cardiology, Tokyo Medical University
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.07.012] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097-137. [PMID: 23166210 DOI: 10.1161/cir.0b013e3182776f83] [Citation(s) in RCA: 276] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Cardiac Outcomes With Submaximal Normal Stress Echocardiography. J Am Coll Cardiol 2012; 60:1393-401. [DOI: 10.1016/j.jacc.2012.05.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 05/28/2012] [Accepted: 06/19/2012] [Indexed: 11/24/2022]
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Yao SS, Wever-Pinzon O, Zhang X, Bangalore S, Chaudhry FA. Prognostic value of stress echocardiogram in patients with angiographically significant coronary artery disease. Am J Cardiol 2012; 109:153-8. [PMID: 22019207 DOI: 10.1016/j.amjcard.2011.08.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 08/18/2011] [Accepted: 08/18/2011] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to evaluate the prognostic value of stress echocardiography in patients with angiographically significant coronary artery disease (CAD). Two hundred sixty patients (mean age 63 ± 10 years, 58% men) who underwent stress echocardiography (41% treadmill, 59% dobutamine) and coronary angiography within 3 months and without intervening coronary revascularization were evaluated. All patients had significant CAD as defined by coronary stenosis ≥70% in major epicardial vessels or branches (45% had single-vessel disease, and 55% had multivessel disease). The left ventricle was divided into 16 segments and scored on a 5-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of ≥1 grade). Follow-up (3.1 ± 1.2 years) for nonfatal myocardial infarction (n = 23) and cardiac death (n = 6) was obtained. In patients with angiographically significant CAD, stress echocardiography effectively risk stratified normal (no ischemia, n = 91) in contrast to abnormal (ischemia, n = 169) groups for cardiac events (event rate 1.0%/year vs 4.9%/year, p = 0.01). Multivariate logistic regression analysis identified multivessel CAD (hazard ratio 2.53, 95% confidence interval 1.16 to 5.51, p = 0.02) and number of segments in which ischemia was present (hazard ratio 4.31, 95% confidence interval 1.29 to 14.38, p = 0.01) as predictors of cardiac events. A Cox proportional-hazards model for cardiac events showed small, significant incremental value of stress echocardiography over coronary angiography (p = 0.02) and the highest global chi-square value for both (p = 0.004). In conclusion, in patients with angiographically significant CAD, (1) normal results on stress echocardiography conferred a benign prognosis (event rate 1.0%/year), and (2) stress echocardiographic results (no ischemia vs ischemia) added incremental prognostic value to coronary angiographic results, and (3) stress echocardiography and coronary angiography together provided additive prognostic value, with the highest global chi-square value.
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Affiliation(s)
- Siu-Sun Yao
- Valley Health System, Ridgewood, New Jersey, USA
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Abstract
PURPOSE OF REVIEW This article reviews the recent advances in stress echocardiography, with particular attention to articles published in 2010 and 2011. It summarizes the developments in the diagnostic and prognostic capabilities of stress echocardiography, discusses new data regarding the safety of stress echocardiography, and highlights emerging roles for stress echocardiography in the areas of left ventricular assist devices, cardiac transplantation, strain-rate echocardiography, and myocardial perfusion imaging. RECENT FINDINGS Stress echocardiography represents a well validated tool in the diagnosis and assessment of patients with known or suspected coronary artery disease. Recently, data have emerged supporting the prognostic capabilities of stress echocardiography in patients with various levels of systolic dysfunction, diastolic abnormalities, and valvular heart disease. New studies continue to document the safety of stress echocardiography, particularly with regard to arrhythmias, neuropsychiatric symptoms, dosing of dobutamine, and intravenous contrast. Studies are now suggesting that stress echocardiography may play novel roles in the evaluation of patients with left ventricular assist devices or potential donors for cardiac transplantation. Technologic developments in myocardial contrast perfusion imaging, three-dimensional imaging, and strain-rate echocardiography will continue to advance the field. SUMMARY Stress echocardiography represents a dynamic, versatile, and well validated tool for the noninvasive assessment of patients with a wide spectrum of cardiovascular diseases.
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Halpern EJ. Clinical applications of cardiac CT angiography. Insights Imaging 2010; 1:205-222. [PMID: 22347917 PMCID: PMC3259381 DOI: 10.1007/s13244-010-0038-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 07/22/2010] [Accepted: 07/29/2010] [Indexed: 01/07/2023] Open
Abstract
ECG-gated multislice CT provides a cost-effective, non-invasive technology for evaluation of the coronary arteries, as well as for additional clinical applications, which require morphological assessment of the heart and adjacent structures with simultaneous evaluation of the coronary circulation.The excellent negative predictive value of a normal coronary CTA (cCTA) examination excludes the presence of significant coronary disease in the symptomatic patient. Triple rule-out studies provide evaluation of the aorta and pulmonary arteries without loss of image quality in the coronary circulation. The ability to visualize surrounding vascular structures along with the coronary arteries is essential in the evaluation of coronary anomalies.Cardiac CTA is useful in non-coronary applications, including evaluation of the thoracic aorta, cardiac valves and other aspects of cardiac morphology that may require surgical or percutaneous repair. Although radiation exposure is a limitation of cCTA relative to echocardiography and MRI, recent technological advances allow coronary imaging with effective doses as low as 1 mSv.Recent advances in evaluation of coronary plaque morphology as well as myocardial perfusion will allow a more complete noninvasive cardiac assessment in the future and may provide a highly effective method of cardiac risk stratification to facilitate preventive cardiac care.
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Affiliation(s)
- Ethan J. Halpern
- Department of Radiology, Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA 19107-5244 USA
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