The CHADS2 score is a useful predictor of coronary arteriosclerosis on 320 slice CT and may correlate with prognosis in subjects with atrial fibrillation

No impact of sub-clinical coronary artery disease identified by cardiac CT scan on the recurrence of atrial fibrillation after a single ablation procedure

BACKGROUND

Performing a cardiac CT scan before ablation provides a better understanding of the anatomical variations of the left atrium and pulmonary veins, as well as an analysis of coronary anatomy and the calcium score. The aim of the present study was to determine whether the CT characteristics of patients with unknown CAD have an impact on recurrence of AF.

METHODS

This monocentric retrospective study included patients with AF who had undergone cardiac CT prior to a single ablation.

RESULTS

Among the 229 patients included in the study, 70 (30.5%) presented AF recurrence between 3 and 12 months after a single ablation. The prevalence of CAD confirmed by CT coronary angiogram and the coronary calcium score were similar in the two groups. Patients with recurrent atrial fibrillation had a significantly higher LAVI evaluated by CT scan than patients without recurrence. The ROC curve determined an optimal LAVI threshold of 49 mL/m². In multivariate analysis, the LAVI measured by CT scan was independently associated with the risk of AF recurrence.

CONCLUSIONS

Our study confirms that CAD is not a predictor of AF recurrence after a single ablation, unlike the LAVI. Further studies are necessary to re-evaluate the long-term conclusions of this work.

CHADS2, CHA2DS2-VASc and R2CHADS2 scores predict mortality in patients with coronary artery disease

Few studies to date address the predictive ability of CHA₂DS₂-VASc and R₂CHADS₂ in CAD patients. Our aim is to investigate the prognostic performance of CHADS₂, CHA₂DS₂-VASc and R₂CHADS₂ scores in patients with coronary artery disease (CAD). Angiographically obstructive CAD patients were enrolled. The prognostic performance of the three risk scores was evaluated using Cox hazards models. In addition, we compared their predictive values by calculating C statistics, net reclassification improvement (NRI) and integrated discrimination improvement (IDI). The endpoints are death from any cause and cardiovascular death. Of 3295 subjects with CAD, the mean CHADS₂, CHA₂DS₂-VASc and R₂CHADS₂ scores are 1.2 ± 1.0, 2.4 ± 1.4, and 1.6 ± 1.4, respectively. The CHADS₂-guided risk classification is markedly distinct from CHA₂DS-₂-VASc- and R₂CHADS₂-guided ones. Over a median follow-up of 24 months, a total of 290 (rate 4.00/100 person-year) deaths occurred, and 163 (rate 2.2/100 person-year) were attributed to cardiovascular deaths. Event rates increase by CHADS₂, CHA₂DS₂-VASc and R₂CHADS₂ (P for trend <0.001). The multivariate analyses show 60, 111 and 82% higher risk of mortality per unit increase of CHADS₂, CHA₂DS₂-VASc and R₂CHADS₂ scores, respectively. Comparing with CHADS₂ score (c-statistic = 0.61), CHA₂DS₂-VASc (c-statistic 0.65, NRI 0.52 and IDI 0.06, P for all <0.05) and R₂CHADS₂ (c-statistic 0.66, NRI 0.43 and IDI 0.09, P for all <0.05) scores provide better discrimination and reclassification for mortality. Also, CHA₂DS₂-VASc and R₂CHADS₂ have comparable predictive ability of mortality to the GRACE score. The CHADS₂, CHA₂DS₂-VASc and R₂CHADS₂ scores are simple yet robust prognostic tools in CAD patients.

Role of risk stratification and genetics in sudden cardiac death

Sudden cardiac death (SCD) is a major public health issue due to its increasing incidence in the general population and the difficulty in identifying high-risk individuals. Nearly 300 000 - 350 000 patients in the United States and 4-5 million patients in the world die annually from SCD. Coronary artery disease and advanced heart failure are the main etiology for SCD. Ischemia of any cause precipitates lethal arrhythmias, and ventricular tachycardia and ventricular fibrillation are the most common lethal arrhythmias precipitating SCD. Pulseless electrical activity, bradyarrhythmia, and electromechanical dissociation also result in SCD. Most SCDs occur outside of the hospital setting, so it is difficult to estimate the public burden, which results in overestimating the incidence of SCD. The insufficiency and limited predictive value of various indicators and criteria for SCD result in the increasing incidence. As a result, there is a need to develop better risk stratification criteria and find modifiable variables to decrease the incidence. Primary and secondary prevention and treatment of SCD need further research. This critical review is focused on the etiology, risk factors, prognostic factors, and importance of risk stratification of SCD.

Intravascular ultrasound for morphological assessment of napkin-ring sign detected on multidetector computed tomography

BACKGROUND

Although napkin-ring sign (NRS) plaques assessed by multidetector computed tomography (MDCT) is identified as a high-risk feature, the detailed morphological features are still unknown. The purpose of this study was to elucidate the morphological features of the MDCT-assessed NRS using intravascular ultrasound (IVUS).

METHODS

We evaluated 204 plaques in 193 patients with non-ST-elevation acute coronary syndrome who were diagnosed using 128-slice MDCT and were assessed using IVUS prior to coronary intervention. Morphology was compared between plaques with and without MDCT-assessed NRS. Severe IVUS-assessed attenuation was defined as an attenuation angle >180°.

RESULTS

NRS was detected in 49 lesions. MDCT-assessed plaque attenuation was lower (p<0.0001), and cross-sectional plaque areas at lesion sites, remodeling index, and the prevalence of positive remodeling were greater, in lesions with NRS (p<0.005, p<0.0001, and p<0.0001, respectively). Furthermore, the IVUS-assessed remodeling index and prevalence of severe attenuation and speckled echo appearance were significantly greater in lesions with NRS (p<0.01, p<0.0001, and p<0.0001, respectively). Using multivariate analysis, IVUS-assessed speckled echo appearance was identified as an independent predictor of MDCT-assessed NRS (odds ratio, 3.59; 95% confidence interval, 1.49-8.66; p<0.005).

CONCLUSION

MDCT assessment of NRS may be associated with larger heterogeneous necrotic cores and greater positive remodeling.