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Coronary artery disease and its risk factors in patients presenting for liver transplantation. J Clin Anesth 2013; 25:618-23. [PMID: 23994032 DOI: 10.1016/j.jclinane.2013.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 06/17/2013] [Accepted: 06/27/2013] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To determine the distribution of coronary artery disease (CAD) and its risk factors across the various etiologies of end-stage liver disease, and to elucidate the relationship between severe alcohol consumption and CAD. DESIGN Retrospective multicenter study analysis. SETTING National Standard Transplant Analysis and Research file data. MEASUREMENTS Data from all primary adult orthotopic liver transplant recipients during the period from 2004 through 2006 were studied. Data were divided into 5 groups according to each patient's etiology of end-stage liver disease. The prevalence of CAD and the distribution of its risk factors were compared among groups. MAIN RESULTS 17,482 cases were studied. The incidence of CAD was highest in nonalcoholic hepatic steatosis (7.4%) and lowest in biliary cirrhosis (1.7%). No difference in prevalence of CAD and its risk factors was noted between the viral and alcoholic etiologies (Hepatitis C 2.7%, Hepatitis B 2.3%, and alcoholic cirrhosis 2.9%). CONCLUSIONS Prevalence of CAD and the distribution of CAD risk factors in patients with severe alcohol consumption were similar to patients with viral hepatitis. CAD was most prevalent in patients with hepatic steatosis. This study argues against the notion of decreased expression and progression of CAD in patients with alcoholic cirrhosis presenting for liver transplantation.
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Henry TD, Satran D, Hodges JS, Johnson RK, Poulose AK, Campbell AR, Garberich RF, Bart BA, Olson RE, Boisjolie CR, Harvey KL, Arndt TL, Traverse JH. Long-term survival in patients with refractory angina. Eur Heart J 2013; 34:2683-8. [DOI: 10.1093/eurheartj/eht165] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Goykhman P, Mehta PK, Agarwal M, Shufelt C, Slomka PJ, Yang Y, Xu Y, Shaw LJ, Berman DS, Merz NB, Thomson LEJ. Reproducibility of myocardial perfusion reserve - variations in measurements from post processing using commercially available software. Cardiovasc Diagn Ther 2012; 2:268-77. [PMID: 24282727 PMCID: PMC3839165 DOI: 10.3978/j.issn.2223-3652.2012.10.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 10/11/2012] [Indexed: 01/20/2023]
Abstract
PURPOSE Adenosine stress first pass cardiac magnetic resonance imaging (CMRI) is a rapidly evolving tool in the diagnosis of ischemic heart disease (IHD). The rest and stress first pass myocardial perfusion data may be interpreted using commercially available software for calculation of time intensity curves in order to generate a numeric value of the segmental or whole heart myocardial perfusion reserve index (MPRI). The objective of this study was to determine the inter- and intra-observer reliability of the data generated by standard commercially available software. METHODS Data from 20 adenosine stress CMRI (1.5 T) studies were analyzed using commercially available CAAS MRV 3.3 software (Pie Medical Imaging B.V., Netherlands) for calculation of the MPRI. The stress CMRI was performed using a standardized protocol in 20 women including 10 women with angina and the absence of obstructive CAD and 10 healthy volunteers. MPRI calculation was made in a standardized manner on separate occasions by two independent observers. A single observer repeated the calculation of MPRI three months later, without reference to the prior data. Basal, mid, and apical segments, for the whole myocardium, sub-endocardium, and sub-epicardium were analyzed. Intra-class correlation coefficients (ICC), repeatability coefficients (RC), and coefficients of variation (CoV) were determined. RESULTS The MPRI results by repeated software measurements were highly correlated, with potentially important variations in measurement observed. The myocardial inter-observer ICC was 0.80 (95% CI, 0.57, 0.92) with a CoV of 7.5%, and intra-observer ICC was 0.89 (95% CI, 0.77, 0.95) with a CoV of 3.6%. The mid-ventricular level MPRI was most reproducible, with intra-observer ICC at 0.91 (95% CI, 0.77, 0.97); intra-observer measurement was more reproducible than inter-observer measurement. CONCLUSIONS There is variation in measurement of MPRI observed in post processing of perfusion data when using a standardized approach and commercially available software. This has implications in the interpretation of data obtained for clinical and research purposes.
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Affiliation(s)
- Pavel Goykhman
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Puja K. Mehta
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Megha Agarwal
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Chrisandra Shufelt
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Piotr J. Slomka
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yuching Yang
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Yuan Xu
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Leslee J. Shaw
- Program in Cardiovascular Outcomes Research and Epidemiology, Emory University, Atlanta, GA, USA
| | - Daniel S. Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Noel Bairey Merz
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Louise E. J. Thomson
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Ishimori ML, Martin R, Berman DS, Goykhman P, Shaw LJ, Shufelt C, Slomka PJ, Thomson LEJ, Schapira J, Yang Y, Wallace DJ, Weisman MH, Bairey Merz CN. Myocardial ischemia in the absence of obstructive coronary artery disease in systemic lupus erythematosus. JACC Cardiovasc Imaging 2011; 4:27-33. [PMID: 21232700 DOI: 10.1016/j.jcmg.2010.09.019] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 09/03/2010] [Accepted: 09/07/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES the purpose of this study was to evaluate the presence of myocardial ischemia measured by adenosine stress cardiac magnetic resonance (CMR) using visual myocardial perfusion and a quantitative myocardial perfusion reserve index (MPRI) in the absence of obstructive coronary artery disease (CAD) in women with systemic lupus erythematosus (SLE) with anginal chest pain (CP). BACKGROUND ischemic heart disease is a leading cause of morbidity and mortality in SLE. Previous studies demonstrated the presence of perfusion defects using adenosine stress CMR in patients with CP and no obstructive CAD, consistent with microvascular coronary dysfunction in patients without SLE. METHOD Twenty female SLE patients with typical and atypical anginal CP were prospectively enrolled. Patients with established cardiovascular disease were excluded. CMR was performed with 0.05 mmol/kg gadolinium adenosine stress first-pass perfusion in SLE patients and in 10 asymptomatic reference control women. SLE patients also underwent 64-slice coronary computed tomography angiography. CMR was scored visually and quantitatively (MPRI). RESULTS among 18 patients with complete data, no patient had obstructive CAD; however, 8 of 18 (44%) displayed visual perfusion defects on stress CMR compared with 0 in 10 control subjects (p = 0.014). The mean MPRI in patients versus controls was 2.0 ± 0.4 versus 2.4 ± 0.4 (p = 0.031) in the subepicardium and 1.8 ± 0.3 versus 2.1 ± 0.4 (p = 0.24) in the subendocardium. Multivariate linear regression revealed that SLE was the only predictor of subepicardial (p < 0.0025; β = -1.059) and subendocardial (p < 0.05; β = -0.529) MPRIs. CONCLUSIONS we observed a 44% prevalence of abnormal stress myocardial perfusion by CMR in the absence of obstructive CAD in SLE patients with anginal CP. Compared with controls, reduced MPRI was observed in SLE patients, and SLE presence was a significant predictor of an abnormal MPRI. These findings are consistent with the hypothesis that anginal CP in SLE patients without obstructive CAD is due to myocardial ischemia potentially caused by microvascular coronary dysfunction. Further research in a larger SLE population is warranted.
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Affiliation(s)
- Mariko L Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Pennell DJ, Keenan NG. Coronary microvascular dysfunction in systemic lupus erythematosus identified by CMR imaging. JACC Cardiovasc Imaging 2011; 4:34-6. [PMID: 21232701 DOI: 10.1016/j.jcmg.2010.11.007] [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] [Received: 10/12/2010] [Accepted: 11/10/2010] [Indexed: 01/03/2023]
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D'Andrea A, Nistri S, Castaldo F, Galderisi M, Mele D, Agricola E, Losi MA, Mondillo S, Marino PN. The relationship between early left ventricular myocardial alterations and reduced coronary flow reserve in non-insulin-dependent diabetic patients with microvascular angina. Int J Cardiol 2010; 154:250-5. [PMID: 21035209 DOI: 10.1016/j.ijcard.2010.09.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/10/2010] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate left ventricular (LV) systolic and diastolic myocardial function, and their relation to coronary flow reserve in patients with non-insulin-dependent diabetes mellitus (DM) and microvascular angina. METHODS AND RESULTS We selected a population of 45 normotensive patients with DM (56.3 ± 8.2 years; 25 males) with LV ejection fraction >50% and microvascular angina (anginal pain, positive imaging stress test and normal coronary angiography). Thirty-five age- and sex-matched healthy controls were also enrolled. All the patients underwent standard echocardiography, Tissue Doppler (TDI), two-dimensional strain (2DSE) imaging, and coronary flow reserve (CFR) measurement. LV myocardial early diastolic peak velocities (E(m)) and peak systolic 2DSE were reduced in both interventricular septum (IVS) and LV lateral wall (p<0.01) in DM, as well as CFR (1.89 ± 0.7 vs 2.55 ± 0.56, p<0.0001) compared with controls. By multivariate analysis, the independent determinants of E(m) were glycated haemoglobin (β coefficient=-0.36; p<0.01) and age (β=-0.46, p<0.001), while global longitudinal strain was predicted by glycated haemoglobin (β=0.48, P<0.001) and by the duration of the disease (β=0.38, P<0.005). An independent association between LV global longitudinal strain and CFR (β coefficient=-0.47, p<0.001) in DM patients was also evidenced. CONCLUSIONS TDI, 2DSE and CFR are valuable non-invasive and easy-repeatable tools for detecting LV myocardial and coronary function in DM patients with microvascular angina.
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Doyle M, Weinberg N, Pohost GM, Bairey Merz CN, Shaw LJ, Sopko G, Fuisz A, Rogers WJ, Walsh EG, Johnson BD, Sharaf BL, Pepine CJ, Mankad S, Reis SE, Vido DA, Rayarao G, Bittner V, Tauxe L, Olson MB, Kelsey SF, Biederman RWW. Prognostic value of global MR myocardial perfusion imaging in women with suspected myocardial ischemia and no obstructive coronary disease: results from the NHLBI-sponsored WISE (Women's Ischemia Syndrome Evaluation) study. JACC Cardiovasc Imaging 2010; 3:1030-6. [PMID: 20947048 PMCID: PMC3278772 DOI: 10.1016/j.jcmg.2010.07.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 07/09/2010] [Accepted: 07/13/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the prognostic value of global magnetic resonance (MR) myocardial perfusion imaging (MPI) in women with suspected myocardial ischemia and no obstructive (stenosis <50%) coronary artery disease (CAD). BACKGROUND The prognostic value of global MR-MPI in women without obstructive CAD remains unknown. METHODS Women (n = 100, mean age 57 ± 11 years, age range 31 to 76 years), with symptoms of myocardial ischemia and with no obstructive CAD, as assessed by coronary angiography, underwent MR-MPI and standard functional assessment. During follow-up (34 ± 16 months), time to first adverse event (death, myocardial infarction, or hospitalization for worsening anginal symptoms) was analyzed using global MPI and left ventricular ejection fraction (EF) data. RESULTS Adverse events occurred in 23 (23%) women. Using univariable Cox proportional hazards regression modeling, variables found to be predictive of adverse events were global MR-MPI average uptake slope (p < 0.05), the ratio of MR-MPI peak signal amplitude to uptake slope (p < 0.05), and EF (p < 0.05). Two multivariable Cox models were formed, 1 using variables that were performance site dependent: ratio of MR-MPI peak amplitude to uptake slope together with EF (chi square: 13, p < 0.005); and a model using variables that were performance site independent: MR-MPI slope and EF (chi square: 12, p < 0.005). Each of the 2 multivariable models remained predictive of adverse events after adjustment for age, disease history, and Framingham risk score. For each of the Cox models, patients were categorized as high risk if they were in the upper quartile of the model and as not high risk otherwise. Kaplan-Meier analysis of time to event was performed for high risk versus not high risk for site-dependent (log rank: 15.2, p < 0.001) and site-independent (log rank: 13.0, p < 001) models. CONCLUSIONS Among women with suspected myocardial ischemia and no obstructive CAD, MR-MPI-determined global measurements of normalized uptake slope and peak signal uptake, together with global functional assessment of EF, appear to predict prognosis.
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Affiliation(s)
- Mark Doyle
- Division of Cardiology, CV MRI Center, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212-4772, USA.
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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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Modonesi E, Balbi M, Bezante GP. Limitations and potential clinical application on contrast echocardiography. Curr Cardiol Rev 2010; 6:24-30. [PMID: 21286275 PMCID: PMC2845791 DOI: 10.2174/157340310790231653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 07/29/2009] [Accepted: 08/03/2009] [Indexed: 01/25/2023] Open
Abstract
Myocardial contrast echocardiography (MCE) is a relatively simple myocardial perfusion imaging technique which should be used in different clinical settings. The ability of MCE to provide a comprehensive assessment of cardiac structure, function, and perfusion is likely to make it the technique of choice for non-invasive cardiac imaging.Contrast agents are encapsulated microbubbles (MB) filled with either air or high-molecular-weight gas. They are innocuous, biologically inert and when administered intravasculary, the sound backscatter from the blood poll is enhanced because MB have the enormous reflective ability due to a large acoustic impedance mismatch between the bubble gas and surrounding blood.MCE is an ideal imaging tool for the assessment of left heart contrast and the myocardial microcirculation. MCE detects contrast MB at the capillary level within the myocardium and, thus, has the potential to assess tissue viability and the duration of the contrast effect. MCE was equivalent to SPECT for the detection of CAD with a tendency toward higher sensitivity of MCE compared with SPECT in microvascular disease and CAD. MCE is also a bedside technique that can be used early in patients presenting with acute heart failure to rapidly assess LV function (regional and global) and perfusion (rest and stress).
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Affiliation(s)
| | | | - Gian Paolo Bezante
- Department of Cardionephrology and Department of Internal Medicine, University of Genoa, Genoa, Italy
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The gold standard for noninvasive imaging in coronary heart disease: magnetic resonance imaging. Curr Opin Cardiol 2009; 24:567-79. [DOI: 10.1097/hco.0b013e3283315553] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Clinical trials report. Curr Cardiol Rep 2008; 10:209-10. [DOI: 10.1007/s11886-008-0035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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