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Perry AS, Dooley EE, Master H, Spartano NL, Brittain EL, Gabriel KP. Physical Activity Over the Lifecourse and Cardiovascular Disease. Circ Res 2023; 132:1725-1740. [PMID: 37289900 PMCID: PMC10254078 DOI: 10.1161/circresaha.123.322121] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Despite improvements in cardiovascular care in recent decades, cardiovascular disease (CVD) remains a leading cause of death worldwide. At its core, CVD is a largely preventable disease with diligent risk factor management and early detection. As highlighted in the American Heart Association's Life's Essential 8, physical activity plays a central role in CVD prevention at an individual and population level. Despite pervasive knowledge of the numerous cardiovascular and noncardiovascular health benefits of physical activity, physical activity has steadily decreased over time and unfavorable changes in physical activity occur throughout people's lives. Here, we use a lifecourse framework to examine the evidence reporting on the association of physical activity with CVD. From in utero to older adults, we review and discuss the evidence detailing how physical activity may prevent incident CVD and mitigate CVD-related morbidity and death across all life stages.
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Affiliation(s)
- Andrew S. Perry
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Erin E. Dooley
- Department of Epidemiology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hiral Master
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Nicole L. Spartano
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Evan L. Brittain
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Kelley Pettee Gabriel
- Department of Epidemiology, The University of Alabama at Birmingham, Birmingham, AL, USA
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Pezel T, Bonnet G, Kinnel M, Asselin A, Hovasse T, Unterseeh T, Champagne S, Sanguineti F, Toupin S, Garot P, Garot J. Clustering of patients with inconclusive non-invasive stress testing referred for vasodilator stress cardiovascular magnetic resonance. Arch Cardiovasc Dis 2022; 115:627-636. [PMID: 36376207 DOI: 10.1016/j.acvd.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/12/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inconclusive non-invasive stress testing is associated with impaired outcome. This population is very heterogeneous, and its characteristics are not well depicted by conventional methods. AIMS To identify patient subgroups by phenotypic unsupervised clustering, integrating clinical and cardiovascular magnetic resonance data to unveil pathophysiological differences between subgroups of patients with inconclusive stress tests. METHODS Between 2008 and 2020, consecutive patients with a first inconclusive non-invasive stress test referred for stress cardiovascular magnetic resonance were followed for the occurrence of major adverse cardiovascular events (defined as cardiovascular death or myocardial infarction). A cluster analysis was performed on clinical and cardiovascular magnetic resonance variables. RESULTS Of 1402 patients (67% male; mean age 70±11years) who completed the follow-up (median 6.5years, interquartile range 5.6-7.5years), 197 experienced major adverse cardiovascular events (14.1%). Three distinct phenogroups were identified based upon unsupervised hierarchical clustering of principal components: phenogroup 1=history of percutaneous coronary intervention with viable myocardial infarction and preserved left ventricular ejection fraction; phenogroup 2=atrial fibrillation with preserved left ventricular ejection fraction; and phenogroup 3=coronary artery bypass graft with non-viable myocardial scar and reduced left ventricular ejection fraction. Using survival analysis, the occurrence of major adverse cardiovascular events (P=0.007), cardiovascular mortality (P=0.002) and all-cause mortality (P<0.001) differed among the three phenogroups. Phenogroup 3 presented the worse prognosis. In each phenogroup, ischaemia was associated with major adverse cardiovascular events (phenogroup 1: hazard ratio 2.79, 95% confidence interval 1.61-4.84; phenogroup 2: hazard ratio 2.59, 95% confidence interval 1.69-3.97; phenogroup 3: hazard ratio 3.16, 95% confidence interval 1.82-5.49; all P<0.001). CONCLUSIONS Cluster analysis of clinical and cardiovascular magnetic resonance variables identified three phenogroups of patients with inconclusive stress testing, with distinct prognostic profiles.
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Affiliation(s)
- Théo Pezel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France; Department of Cardiology, Lariboisière Hospital, AP-HP, Inserm UMRS 942, University of Paris, 75010 Paris, France
| | - Guillaume Bonnet
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
| | - Marine Kinnel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | | | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Solenn Toupin
- Scientific Partnerships Division, Siemens Healthcare France, 93200 Saint-Denis, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France
| | - Jérôme Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300 Massy, France.
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Sonaglioni A, Rigamonti E, Nicolosi GL, Lombardo M. Prognostic Value of Modified Haller Index in Patients with Suspected Coronary Artery Disease Referred for Exercise Stress Echocardiography. J Cardiovasc Echogr 2021; 31:85-95. [PMID: 34485034 PMCID: PMC8388326 DOI: 10.4103/jcecho.jcecho_141_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/17/2021] [Indexed: 01/28/2023] Open
Abstract
Background: The influence of chest conformation on outcome of patients with suspected coronary artery disease (CAD) is actually unknown. Materials and Methods: This retrospective study included all consecutive patients who underwent exercise stress echocardiography (ESE) for suspected CAD at our institution between February 2011 and September 2019. Modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. During the follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations and (2) cardiac death or sudden death. Results: A total of 1091 consecutive patients (62.4 ± 12.6 years, 57.2% of men) were included in the study. Patients with normal chest shape (MHI ≤2.5) and those with concave-shaped chest wall (MHI >2.5) were separately analyzed. A positive ESE was diagnosed in 171 patients of which 80.7% had an obstructive CAD (true positive), while 19.3 not (false positive [FP]). Majority of FP ESE (70.9%) derived from concave-shaped chest wall group. During follow-up time (2.5 ± 1.9 years), 9 patients died and 281 were hospitalized because of heart failure (163), acute coronary syndromes (39), and arrhythmias (79). At the multivariate Cox regression analysis, age (heart rate [HR]: 1.02, 95% confidence interval [CI]: 1.01–1.03), MHI >2.5 (HR: 0.39, 95% CI: 0.26–0.56), diabetes mellitus (HR: 4.89, 95% CI: 3.78–6.32), horizontal ST depression ≥1 mm (HR: 2.86, 95% CI: 1.98–4.15), peak exercise average E/e' ratio (HR: 1.08, 95% CI: 1.06–1.10), and peak exercise wall motion score index (HR: 1.79, 95% CI: 1.36–2.35) were independently correlated with outcome. Conclusions: Patients with concave-shaped chest wall (MHI >2.5) have a significantly lower probability of CV events than those with normal chest shape (MHI ≤2.5) over a medium-term follow-up. A noninvasive chest shape assessment could identify subjects at lower risk of CV events.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, San Giuseppe MultiMedica Hospital, Milan, Italy
| | | | | | - Michele Lombardo
- Department of Cardiology, San Giuseppe MultiMedica Hospital, Milan, Italy
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Kadoglou NPE, Papadopoulos CH, Papadopoulos KG, Karagiannis S, Karabinos I, Loizos S, Theodosis-Georgilas A, Aggeli K, Keramida K, Klettas D, Kounas S, Makavos G, Ninios I, Ntalas I, Ikonomidis I, Sahpekidis V, Stefanidis A, Zaglavara T, Athanasopoulos G, Karatasakis G, Kyrzopoulos S, Kouris N, Patrianakos A, Paraskevaidis I, Rallidis L, Savvatis K, Tsiapras D, Nihoyannopoulos P. Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: an expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology. Hellenic J Cardiol 2021; 64:30-57. [PMID: 34329766 DOI: 10.1016/j.hjc.2021.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022] Open
Abstract
Stress echocardiography (SE) is a well-established and valid technique, widely-used for the diagnostic evaluation of patients with ischemic and non-ischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of current medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training, focusing on the preparation, the protocols used and the analysis of the SE images and an updated, evidence-based knowledge about SE applications on ischemic and non-ischemic heart diseases, such as in cardiomyopathies, heart failure and valvular heart disease.
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Affiliation(s)
- Nikolaos P E Kadoglou
- Medical School, University of Cyprus, Nicosia, Cyprus; Second Cardiology Department, "Hippokration" Hospital, Aristotle University ofThessaloniki, Greece.
| | | | | | | | | | | | | | - Konstantina Aggeli
- 1st Cardiology Department, Hippokration University Hospital, Athens, Greece
| | - Kalliopi Keramida
- 2nd Cardiology Department, Attikon University Hospital, Athens, Greece
| | | | | | - George Makavos
- 3rd Cardiology Department, Sotiria University Hospital, Athens, Greece
| | - Ilias Ninios
- 2nd Cardiology Department, Interbalkan Center, Thessaloniki, Greece
| | | | | | | | | | | | | | - George Karatasakis
- 1st Cardiology Department, Onassis Cardiosurgical Center, Piraeus, Greece
| | | | - Nikos Kouris
- Cardiology Department, Thriasio Hospital, Elefsina, Greece
| | | | | | | | | | - Dimitrios Tsiapras
- 2nd Cardiology Department, Onassis Cardiosurgical Center, Piraeus, Greece
| | - Petros Nihoyannopoulos
- Metropolitan Hospital Center, Piraeus, Greece; Imperial College London, Hammersmith Hospital, London, UK
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5
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Pezel T, Unterseeh T, Garot P, Hovasse T, Kinnel M, Champagne S, Toupin S, Sanguineti F, Garot J. Prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance after inconclusive stress testing. J Cardiovasc Magn Reson 2021; 23:89. [PMID: 34218805 PMCID: PMC8256486 DOI: 10.1186/s12968-021-00785-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND While current guidelines recommend noninvasive testing to detect coronary artery disease, stress tests are deemed inconclusive in a quarter of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized. To assess the prognostic value of vasodilator stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing. METHODS Between 2008 and 2020, consecutive patients with a first non-CMR inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter. RESULTS Of 1563 patients who completed the CMR protocol, 1402 patients (66.7% male, 69.5 ± 11.0 years) completed the follow-up (median [interquartile range], 6.5 [5.6-7.5] years); 197 experienced a MACE (14.1%). Vasodilator stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.88 [95% CI 2.18-3.81]; and HR: 1.46 [95% CI 1.16-1.89], both p < 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95% CI 1.89-3.40]; and HR: 1.58 [95% CI 1.47-1.71]; both p < 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95% CI 0.69-0.81] with C-statistic improvement: 0.12). The study suggested no benefit of CMR-related coronary revascularization in reducing MACE. CONCLUSIONS In patients with a first non-CMR inconclusive stress test, vasodilator stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.
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Affiliation(s)
- Théo Pezel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, 21287-0409, USA
| | - Thierry Unterseeh
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Marine Kinnel
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Stéphane Champagne
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Solenn Toupin
- Siemens Healthcare France, 93200, Saint-Denis, France
| | - Francesca Sanguineti
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France
| | - Jérôme Garot
- Institut Cardiovasculaire Paris Sud, Cardiovascular Magnetic Resonance Laboratory, Hôpital Privé Jacques Cartier, Ramsay Santé, 6 Avenue du Noyer Lambert, 91300, Massy, France.
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Bombardini T, Pacini D, Potena L, Maccherini M, Kovacevic-Preradovic T, Picano E. Heart rate reserve during dipyridamole stress test applied to potential heart donors in brain death. Minerva Cardioangiol 2020; 68:249-257. [PMID: 32100982 DOI: 10.23736/s0026-4725.20.05093-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND A blunted heart rate reserve (HRR) during dipyridamole stress echocardiography (DSE) is a prognostically unfavorable sign of cardiac autonomic dysfunction. Short-term adjustments of heart rate (HR) are thought to rise from changes in neural input to the heart. DSE is applied in potential heart donors to rule out underlying coronary artery disease and left ventricular dysfunction. The aim of this study is to assess HRR during DSE in brain death. METHODS We enrolled two groups: group 1 (N.=49, 22 men, 54.6±8.8 years) with patients in brain death enrolled in the nationwide marginal donor heart recruiting program; group 2 (N.=49, 18 men, 66.4±12.0 years) referred to DSE for suspected or known coronary artery disease. All underwent DSE (0.84 mg/kg in 6') by quality-controlled readers certified via web-based training (1487/CE Lazio-1). We assessed left ventricular contractile reserve (LVCR) as stress/rest ratio of force (systolic blood pressure/end-systolic volume). HRR was calculated as the peak/rest HR ratio from 12-lead EKG. RESULTS The two study groups were similar for prevalence of inducible ischemia (4/49 vs. 9/49, P=NS). Group 1 showed higher resting HR (group 1: 88.1±15.5 bpm vs. group 2: 66.5±11.5 bpm, P<0.01) and similar peak HR (group 1: 94.7±15.3 bpm vs. group 2: 89.5±19.3 bpm, P=0.144), with blunted HRR (group 1: 1.08±0.10 bpm vs. group 2: 1.36±0.31 bpm, P<0.01). HRR was unrelated to LVCR. CONCLUSIONS HRR is almost abolished and unrelated to LVCR in brain-dead patients during DSE. The modulation of neural input to the heart is essential to determine HRR, and plays no significant role in determining the inotropic response during DSE.
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Affiliation(s)
- Tonino Bombardini
- Clinical Center of the Republic of Srpska, Faculty of Medicine, University of Banja-Luka, Banja-Luka, Bosnia and Herzegovina -
| | - Davide Pacini
- Department of Cardiac, Thoracic, and Vascular Surgery, S. Orsola-Malpighi Polyclinic Hospital, Bologna University, Bologna, Italy
| | - Luciano Potena
- Department of Cardiac, Thoracic, and Vascular Surgery, S. Orsola-Malpighi Polyclinic Hospital, Bologna University, Bologna, Italy
| | | | - Tamara Kovacevic-Preradovic
- Clinical Center of the Republic of Srpska, Faculty of Medicine, University of Banja-Luka, Banja-Luka, Bosnia and Herzegovina
| | - Eugenio Picano
- Department of Biomedicine, Institute of Clinical Physiology, National Research Council, Pisa, Italy
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Villines D, Summerfelt WT, Spalding JR, Kitt TM, Kristy RM, Houle CR. Use of Initial Noninvasive Cardiac Testing and Association with Downstream Healthcare Resource: A Retrospective Review of Resources Used Across a 12-Month Window for Probable Type I Myocardial Infarction Patients. PHARMACOECONOMICS - OPEN 2019; 3:527-535. [PMID: 31102147 PMCID: PMC6861412 DOI: 10.1007/s41669-019-0128-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Clinical guidelines provide clinicians with substantial discretion in the use of noninvasive cardiac testing for patients with suspected coronary artery disease. Repeat testing, frequent emergency department (ED) visits, and increases in other cardiac-related procedures can be a burden on patients and payers and can complicate treatment planning. We assessed downstream healthcare resource utilization (HCRU) for patients undergoing initial single-photon emission computed tomography (SPECT), myocardial perfusion imaging (MPI), stress echocardiography (ECHO), or exercise treadmill testing (ETT) with probable type I myocardial infarction (MI). METHODS Electronic medical records data from 12,130 patients with probable type I MI presenting to EDs within a large healthcare system comprised of 11 adult hospitals were retrospectively analyzed. Logistic and linear regression determined the individual contribution of SPECT-MPI, ETT, and ECHO on repeat cardiovascular (CV) testing, inpatient visits, outpatient visits, and cardiac-related costs within 12 months of the index visit. RESULTS The majority of patients received SPECT-MPI for the index-testing event (56.5%), followed by ETT (29.2%) and ECHO (14.3%). Patients who had SPECT-MPI at the index visit were less likely to have a repeat CV testing visit (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62‒0.96; p = 0.020) or an inpatient visit (OR 0.70, 95% CI 0.49‒0.98; p = 0.039) than those who underwent ETT or ECHO. ETT and ECHO were not predictive of any outcome. CONCLUSIONS SPECT-MPI does not result in more downstream HCRU than ETT or ECHO and is associated with a lower likelihood of repeat non-invasive CV testing and inpatient visits.
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Affiliation(s)
- Dana Villines
- Advocate Health Care, 814 W. Nelson St, RM2025, Chicago, IL, 60657, USA.
| | - Wm Thomas Summerfelt
- Advocate Health Care, 814 W. Nelson St, RM2025, Chicago, IL, 60657, USA
- Convergence CT, Chicago, IL, USA
| | | | | | - Rita M Kristy
- Astellas Pharma Global Development, Northbrook, IL, USA
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Whitman M, Jenkins C, Sabapathy S, Adams L. Comparison of heart rate reserve, age predicted maximum heart rate and rate pressure product as predictors of future cardiovascular events following a negative dobutamine stress echocardiogram. Acta Cardiol 2019; 75:659-666. [PMID: 31442096 DOI: 10.1080/00015385.2019.1653566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Dobutamine stress echocardiography (DSE) is a commonly used diagnostic stress test for the assessment of various cardiac pathologies on patients unable to perform exercise. Unlike exercise, there is no reliable subjective termination end-point such as fatigue to rely on. Consequently, DSE's are often concluded at a predetermined age predicted maximal heart rate (APMHR) such as 85%. The aim of this study was to assess if APMHR, heart rate reserve (HRR) and the maximum rate pressure product (MRPP) are valid measures of future cardiovascular (CV) events in otherwise negative DSEs. Methods: Following exclusions, receiver operating curve (ROC) analyses were performed on 652 patients using CV events during the follow-up period (4.2 ± 1.8 years) as the outcome variable. Results: ROC analyses failed to produce a statistically valid model for MRPP (p = .227, area under curve (AUC)=0.55) with a sensitivity and specificity of 21.1% and 91.9%, respectively at the optimal cut point (14948 MRPP). To the contrary, APMHR produced a sensitivity and specificity of 74.7% and 60.9%, respectively (p < .0001, AUC = 0.715). HRR however, with a sensitivity and specificity of 67.4% and 68.2% (p < .0001, AUC = 0.718) was the only predictor of CV events following Cox analysis (p < .0001). Conclusions: This study demonstrates MRPP as a poor measure of CV event prediction during DSE. While an APMHR of 89.3% demonstrated a statistically valid model, HRR was the only predictor of CV events in otherwise negative DSEs.
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Affiliation(s)
- Mark Whitman
- Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
- Menzies Health Institute, Gold Coast, Australia
- Department of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Australia
| | - Carly Jenkins
- Cardiac Investigations Unit, Logan Hospital, Meadowbrook, Australia
| | - Surendran Sabapathy
- Menzies Health Institute, Gold Coast, Australia
- Allied Health Sciences, Griffith University, Gold Coast, Australia
| | - Lewis Adams
- Menzies Health Institute, Gold Coast, Australia
- Allied Health Sciences, Griffith University, Gold Coast, Australia
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Steeds RP, Wheeler R, Bhattacharyya S, Reiken J, Nihoyannopoulos P, Senior R, Monaghan MJ, Sharma V. Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2019; 6:G17-G33. [PMID: 30921767 PMCID: PMC6477657 DOI: 10.1530/erp-18-0068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022] Open
Abstract
Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.
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Affiliation(s)
- Richard P Steeds
- Department of Cardiology, Institute of Cardiovascular Science, University Hospital Birmingham, Birmingham, UK
| | - Richard Wheeler
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | | | - Joseph Reiken
- Department of Cardiology, Kings College Hospital, London, UK
| | - Petros Nihoyannopoulos
- Department of Cardiology, National Heart Lung Institute, Hammersmith Hospital, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Mark J Monaghan
- Department of Cardiology, Kings College Hospital, London, UK
| | - Vishal Sharma
- Department of Cardiology, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
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10
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Xian Quah J, Greaves K, Thomas L, Stanton T. The Clinical Utility and Enduring Versatility of Stress Echocardiography. Heart Lung Circ 2019; 28:1376-1383. [PMID: 31078426 DOI: 10.1016/j.hlc.2019.02.188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/08/2019] [Accepted: 02/01/2019] [Indexed: 01/06/2023]
Abstract
Stress echocardiography is an established cardiac imaging modality for the detection and quantification of severity of coronary artery disease. In recent years, there has also been an increasing use of stress echocardiography in the assessment of non-ischaemic cardiac disease given its ability to assess functional capacity and haemodynamic changes with exercise which can help guide therapy and inform prognosis. The emerging use of strain, myocardial contrast and three-dimensional (3D) echocardiography further assists in improving diagnostic accuracy particularly in patients with coronary artery disease. This paper summarises the protocols, indications and clinical applications of stress echocardiography in both ischaemic and non-ischaemic cardiac disease.
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Affiliation(s)
- Jing Xian Quah
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia; University of the Sunshine Coast, Brisbane, Qld, Australia
| | - Liza Thomas
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tony Stanton
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia; University of the Sunshine Coast, Brisbane, Qld, Australia; School of Medicine, Griffith University, Sunshine Coast University Hospital, Brisbane, Qld, Australia.
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Prevalencia y determinantes clínicos de ecocardiografía de esfuerzo no concluyente en pacientes con dolor torácico. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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12
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Velasco del Castillo S, Antón Ladislao A, Gómez Sánchez V, Onaindia Gandarias JJ, Cacicedo Fernández de Bobadilla Á, Rodríguez Sánchez I, Laraudogoitia Zaldumbide E. Influencia del riesgo cardiovascular en la predicción y el momento de aparición de eventos cardiacos tras ecocardiograma de esfuerzo sin isquemia. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Flores-Blanco PJ, Cambronero F, García-Navarro M, de la Morena G, Valdés M, Manzano-Fernández S. Inconclusive Exercise Stress Echocardiography in Patients With Chest Pain: Prevalence and Clinical Determinants. ACTA ACUST UNITED AC 2017; 71:406-408. [PMID: 28499844 DOI: 10.1016/j.rec.2017.02.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 02/21/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Pedro J Flores-Blanco
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain.
| | - Francisco Cambronero
- Sección de Cardiología, Hospital Los Arcos del Mar Menor, San Javier, Murcia, Spain
| | - Miguel García-Navarro
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Gonzalo de la Morena
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Mariano Valdés
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain; Departamento de Medicina Interna, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
| | - Sergio Manzano-Fernández
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain; Departamento de Medicina Interna, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
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Abreu JSD, Rocha EA, Machado IS, Parahyba IO, Rocha TB, Paes FJVN, Diogenes TCP, Abreu MEBD, Farias AGLP, Carneiro MM, Paes JN. Prognostic Value of Coronary Flow Reserve Obtained on Dobutamine Stress Echocardiography and its Correlation with Target Heart Rate. Arq Bras Cardiol 2017; 108:417-426. [PMID: 28444062 PMCID: PMC5444888 DOI: 10.5935/abc.20170041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 11/30/2016] [Indexed: 11/20/2022] Open
Abstract
Background: Normal coronary flow velocity reserve (CFVR) (≥ 2) obtained in the left anterior descending coronary artery (LAD) from transthoracic echocardiography is associated with a good prognosis, but there is no study correlating CFVR with submaximal target heart rate (HR). Objective: To evaluate the prognostic value of CFVR obtained in the LAD of patients with preserved (>50%) left ventricular ejection fraction (LVEF) who completed a dobutamine stress echocardiography (DSE), considering target HR. Methods: Prospective study of patients with preserved LVEF and CFVR obtained in the LAD who completed DSE. In Group I (GI = 31), normal CFVR was obtained before achieving target HR, and, in Group II (GII = 28), after that. Group III (G III=24) reached target HR, but CFVR was abnormal. Death, acute coronary insufficiency, coronary intervention, coronary angiography without further intervention, and hospitalization were considered events. Results: In 28 ± 4 months, there were 18 (21.6%) events: 6% (2/31) in GI, 18% (5/28) in GII, and 46% (11/24) in GIII. There were 4 (4.8%) deaths, 6 (7.2%) coronary interventions and 8 (9.6%) coronary angiographies without further intervention. In event-free survival by regression analysis, GIII had more events than GI (p < 0.001) and GII (p < 0.045), with no difference between GI and GII (p = 0.160). After adjustment, the only difference was between GIII and GI (p = 0.012). Conclusion: In patients with preserved LVEF and who completed their DSE, normal CFVR obtained before achieving target HR was associated with better prognosis. Fundamento: A reserva de velocidade de fluxo coronariano (RVFC) adequada (≥ 2) obtida na artéria descendente anterior (ADA) através do ecocardiograma transtorácico associa-se a bom prognóstico, mas não há estudo correlacionando-a com a frequência cardíaca (FC) alvo (submáxima). Objetivo: Avaliar o valor prognóstico da RVFC obtida na ADA de pacientes com fração de ejeção do ventrículo esquerdo (FEVE) preservada (>50%) e ecocardiograma sob estresse com dobutamina (EED) concluído, considerando a FC alvo submáxima. Métodos: studo prospectivo de pacientes com FEVE preservada e RVFC obtida na ADA durante EED concluído. No Grupo I (GI=31), a RVFC adequada foi obtida antes de se atingir a FC alvo, e no Grupo II (G II=28), após. O Grupo III (G III=24) atingiu a FC alvo, mas a RVFC foi inadequada. Foram considerados eventos: óbito, insuficiência coronariana aguda, intervenção coronariana, coronariografia sem intervenção subsequente e internamento hospitalar. Resultados: Em 28 ± 4 meses, ocorreram 18 (21,6%) eventos, sendo 6% (2/31) no GI, 18% (5/28) no GII e 46% (11/24) no GIII. Foram 4 (4,8%) óbitos, 6 (7,2%) intervenções coronarianas e 8 (9,6%) coronariografias sem intervenção subsequente. Na sobrevida livre de eventos pela análise de regressão, GIII apresentou mais eventos do que GI (p < 0,001) ou GII (p < 0,045), não havendo diferença entre GI e GII (p = 0,160). Após o ajustamento, foi mantida a diferença apenas entre GIII e GI (p = 0,012). Conclusão: Em pacientes com FEVE preservada e EED concluído, a RVFC adequada obtida antes da FC alvo associou-se ao melhor prognóstico.
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Affiliation(s)
- José Sebastião de Abreu
- Clínica Clinicárdio, de Fortaleza, CE - Brazil.,Hospital Prontocárdio, Fortaleza, CE - Brazil.,Hospital das Clínicas da Universidade Federal do Ceará, Fortaleza, CE - Brazil
| | - Eduardo Arrais Rocha
- Clínica Clinicárdio, de Fortaleza, CE - Brazil.,Hospital Prontocárdio, Fortaleza, CE - Brazil.,Hospital das Clínicas da Universidade Federal do Ceará, Fortaleza, CE - Brazil
| | | | | | | | | | | | | | | | | | - José Nogueira Paes
- Clínica Clinicárdio, de Fortaleza, CE - Brazil.,Hospital Prontocárdio, Fortaleza, CE - Brazil
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15
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Velasco Del Castillo S, Antón Ladislao A, Gómez Sánchez V, Onaindia Gandarias JJ, Cacicedo Fernández de Bobadilla Á, Rodríguez Sánchez I, Laraudogoitia Zaldumbide E. Influence of Cardiovascular Risk in the Prediction and Timing of Cardiac Events After Exercise Echocardiogram Testing Without Ischemia. ACTA ACUST UNITED AC 2017; 70:736-743. [PMID: 28416165 DOI: 10.1016/j.rec.2016.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES There have been no analyses of the influence of cardiovascular risk as a predictor of events in patients with exercise echocardiography (EE) without ischemia. Our objective was to determine the predictors of cardiac events, paying special attention to cardiovascular risk. METHODS This study included 1640 patients with EE without ischemia. Of these, there were 1206 with no previously known coronary artery disease (CAD), whose risk of a fatal cardiovascular disease event was estimated according to the European SCORE (Systematic COronary Risk Evaluation) risk assessment system, and 434 with known CAD. The primary endpoint was cardiac event-free survival (EFS) (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization). RESULTS After a median follow-up of 35 [23-54] months, no differences were found in cardiac EFS between patients with a SCORE ≥ 10 or diabetes and patients with previous CAD (89.8% vs 87.1%). In the first year, cardiac EFS was high in all groups (99.4% if SCORE < 5; 100% if 5-9; 98% if ≥ 10 or diabetes and 97% in patients with CAD). In the third year, cardiac EFS was similar in the group with SCORE ≥ 10 or diabetes (94.5%) and patients with CAD (91.1%, P = NS). In these patients, the annualized event rate was 2.8% and 2.55%, respectively, and was significantly higher than in groups with SCORE < 5 (0.6%) and SCORE 5-9 (0.12%). The most frequent events were non-ST-segment elevation acute coronary syndrome and late revascularization. Predictors of cardiac events were previous CAD, SCORE ≥ 10 or diabetes mellitus, creatinine clearance, left ventricular ejection fraction, and chest pain during EE. CONCLUSIONS Initial outcome after an EE without ischemia is favorable but is subsequently modulated by cardiovascular risk.
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16
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Abreu JS, Tsutsui JM, Falcão SNR, Feitosa JA, Rocha EA, Oliveira ÍM, Diógenes TC, Paes JN, Sbano JC, Dallan LA, Filho RK, Mathias W. The impact of ligation of proximal side branches on blood flow and functional status of the internal thoracic artery in coronary anastomosis. Echocardiography 2016; 33:1656-1664. [PMID: 27480291 DOI: 10.1111/echo.13313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The effect of proximal side branches on the patency of the internal thoracic artery (ITA) is controversial. We used echocardiography and Doppler to verify the effect of ligation of branches on the flow and coronary flow reserve (CFR) of the grafted ITA in patients after coronary artery bypass grafting (CABG). METHODS We prospectively investigated 53 patients with preserved left ventricular ejection fraction (LVEF >50%) who underwent CABG of the ITA. In Group I (25 patients), major branches were ligated during ITA anastomosis to the left anterior descending (LAD) coronary artery, whereas no ligation was performed in Group II (28 patients). Systolic flow (SF), diastolic flow (DF), and total flow (TF = SF + DF) were measured by Doppler echocardiography at the proximal level of the ITA preoperatively, at early postoperative stage, and 6 months after surgery. Dobutamine stress echocardiography (DSE) was performed at 6 months to determine CFR. RESULTS The ITA flow was predominantly systolic before surgery and diastolic in the postoperative period. We found no differences between the groups in DF. On DSE, SF (19.5±9 mL/min vs 32.7±19 mL/min; P=.003) and TF (79±21 mL/min vs 101±47 mL/min; P=.037) were higher in Group II. There were no differences in CFR (1.9±0.46 vs 2.11±0.56; P=.143). CONCLUSION In patients with preserved LVEF, ligation of major side branches during anastomosis to the LAD does not alter ITA flow or CFR.
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Affiliation(s)
- José Sebastião Abreu
- Public Health Department, State University of Ceará, Fortaleza, Brazil.,Prontocárdio Hospital, Fortaleza, Brazil.,Program in Cardiology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Jeane Mike Tsutsui
- Program in Cardiology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | | | | | - João C Sbano
- Program in Cardiology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Luis A Dallan
- Program in Cardiology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Roberto Kalil Filho
- Program in Cardiology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Wilson Mathias
- Program in Cardiology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
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17
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Cortigiani L, Sorbo S, Miccoli M, Scali MC, Simioniuc A, Morrone D, Bovenzi F, Marzilli M, Dini FL. Prognostic value of cardiac power output to left ventricular mass in patients with left ventricular dysfunction and dobutamine stress echo negative by wall motion criteria. Eur Heart J Cardiovasc Imaging 2016; 18:153-158. [PMID: 27129537 DOI: 10.1093/ehjci/jew073] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 03/12/2016] [Indexed: 11/13/2022] Open
Abstract
AIMS Cardiac power output to left ventricular mass (power/mass) is an index of myocardial efficiency reflecting the rate at which cardiac work is delivered with respect to the potential energy stored in the left ventricular mass. In the present study, we sought to investigate the capability of power/mass assessed at peak of dobutamine stress echocardiography to predict mortality in patients with ischaemic cardiomyopathy and no inducible ischaemia. METHODS AND RESULTS One-hundred eleven patients (95 males; age 68 ± 10 years) with 35 ± 7% mean left ventricular ejection fraction and a dobutamine stress echocardiography (up to 40 µg/kg/min) negative by wall motion criteria formed the study population. Power/mass at peak stress was obtained as the product of a constant (K = 2.22 × 10-1) with cardiac output and the mean arterial pressure divided by left ventricular mass to convert the units to W/100 g. Patients were followed up for a median of 29 months (inter-quartile range 16-72 months). All-cause mortality was the only accepted clinical end point. Mean peak-stress power/mass was 0.70 ± 0.31 W/100 g. During follow-up, 29 deaths (26%) were registered. With a receiver operating characteristic analysis, a peak-stress power/mass ≤0.50 W/100 g [area under curve 0.72 (95% CI 0.63; 0.80), sensitivity 59%, specificity 80%] was the best value for predicting mortality. Univariate prognostic indicators were age, male sex, peak-stress ejection fraction, peak-stress stroke volume, peak-stress cardiac output, peak-stress cardiac power output ≤1.48 W, and peak-stress power/mass ≤0.50 W/100 g. At multivariate analysis, age (HR 1.08, 95% CI 1.04; 1.14; P = 0.004) and peak-stress power/mass ≤0.50 W/100 g (HR 4.05, 95% CI 1.36; 12.00; P = 0.01) provided independent prognostic information. Three-year mortality was 14% in patients with peak-stress power/mass >0.50 W/100 g and 47% in those with peak-stress power/mass ≤0.50 W/100 g (log-rank 20.4; P < 0.0001). CONCLUSION Power/mass assessed at peak of dobutamine stress echocardiography allows effective prognostication in patients with ischaemic cardiomyopathy and test result negative by wall motion criteria. In particular, a peak-stress power/mass ≤50 W/100 g is a strong and multivariable predictor of mortality.
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Affiliation(s)
| | - Simone Sorbo
- Cardiac, Thoracic and Vascular Department, University Hospital of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa 56124, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria Chiara Scali
- Cardiac, Thoracic and Vascular Department, University Hospital of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa 56124, Italy
| | - Anca Simioniuc
- Cardiac, Thoracic and Vascular Department, University Hospital of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa 56124, Italy
| | - Doralisa Morrone
- Cardiac, Thoracic and Vascular Department, University Hospital of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa 56124, Italy
| | | | - Mario Marzilli
- Cardiac, Thoracic and Vascular Department, University Hospital of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa 56124, Italy
| | - Frank Lloyd Dini
- Cardiac, Thoracic and Vascular Department, University Hospital of Pisa, Azienda Universitaria-Ospedaliera Pisana, Via Paradisa, 2, Pisa 56124, Italy
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18
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Bouzas-Mosquera A, Peteiro J, Broullón FJ, Álvarez-García N, Rodríguez-Garrido JL, Mosquera VX, Martínez D, Yáñez JC, Vázquez-Rodríguez JM. Incremental value of exercise echocardiography over exercise electrocardiography in a chest pain unit. Eur J Intern Med 2015; 26:720-5. [PMID: 26321649 DOI: 10.1016/j.ejim.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/29/2015] [Accepted: 08/05/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Limited data are available on the added value of exercise echocardiography (ExEcho) over exercise electrocardiography (ExECG) in patients with suspected acute coronary syndromes (ACS) referred to a chest pain unit. We aimed to assess the incremental value of ExEcho over ExECG in this setting. METHODS ExECG and ExEcho were performed in parallel in 1052 patients with suspected ACS, nondiagnostic but interpretable electrocardiograms, and negative serial troponin results. The primary outcome was a composite of coronary death, nonfatal myocardial infarction or unstable angina with angiographic documentation of significant coronary artery disease within 6 months. RESULTS The primary outcome occurred in 2/614 patients (0.3%) with both negative ExECG and ExEcho, 3/60 (5%) with positive ExECG and negative ExEcho, 73/135 (54.1%) with negative ExECG and positive ExEcho, 106/136 (77.9%) with both positive ExECG and ExEcho, and 8/107 (7.5%) with inconclusive results. The addition of ExEcho data to a model based on clinical and ExECG data significantly increased the c statistic from 0.898 to 0.968 (change +0.070, 95% confidence interval 0.052-0.092), with a continuous net reclassification improvement of 1.56 and an integrated discrimination improvement of 22% (p<0.001). Decision curve analysis showed that a strategy of referral to coronary angiography based on ExEcho was associated with the highest net benefit and with the largest reduction in unnecessary coronary angiographies. CONCLUSION ExEcho provides significant incremental prognostic information and higher net clinical benefit than a strategy based on ExECG in patients referred to a chest pain unit for suspected ACS and negative troponin levels.
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Affiliation(s)
| | - Jesús Peteiro
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco J Broullón
- Department of Health Information Technology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | | | - Víctor X Mosquera
- Department of Cardiac Surgery, Hospital Universitario A Coruña, A Coruña, Spain
| | - Dolores Martínez
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Juan C Yáñez
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
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19
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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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20
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Nicolau-Raducu R, Gitman M, Ganier D, Loss GE, Cohen AJ, Patel H, Girgrah N, Sekar K, Nossaman B. Adverse cardiac events after orthotopic liver transplantation: a cross-sectional study in 389 consecutive patients. Liver Transpl 2015; 21:13-21. [PMID: 25213120 DOI: 10.1002/lt.23997] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 09/02/2014] [Accepted: 09/08/2014] [Indexed: 12/18/2022]
Abstract
Current American College of Cardiology/American Heart Association guidelines caution that preoperative noninvasive cardiac tests may have poor predictive value for detecting coronary artery disease in liver transplant candidates. The purpose of our study was to evaluate the role of clinical predictor variables for early and late cardiac morbidity and mortality and the predictive values of noninvasive cardiac tests for perioperative cardiac events in a high-risk liver transplant population. In all, 389 adult recipients were retrospectively analyzed for a median follow-up time of 3.4 years (range = 2.3-4.4 years). Overall survival was 83%. During the first year after transplantation, cardiovascular morbidity and mortality rates were 15.2% and 2.8%. In patients who survived the first year, cardiovascular morbidity and mortality rates were 3.9% and 2%, with cardiovascular etiology as the third leading cause of death. Dobutamine stress echocardiography (DSE) and single-photon emission computed tomography had respective sensitivities of 9% and 57%, specificities of 98% and 75%, positive predictive values of 33% and 28%, and negative predictive values of 89% and 91% for predicting early cardiac events. A rate blood pressure product less than 12,000 with DSE was associated with an increased risk for postoperative atrial fibrillation. Correspondence analysis identified a statistical association between nonalcoholic steatohepatitis/cryptogenic cirrhosis and postoperative myocardial ischemia. Logistic regression identified 3 risk factors for postoperative acute coronary syndrome: age, history of coronary artery disease, and pretransplant requirement for vasopressors. Multivariable analysis showed statistical associations of the Model for End-Stage Liver Disease score and the development of acute kidney injury as risk factors for overall cardiac-related mortality. These findings may help in identifying high-risk patients and may lead to the development of better cardiac tests.
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21
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Parnham SFC, Gleadle JM, De Pasquale CG, Selvanayagam JB. Myocardial Ischemia Assessment in Chronic Kidney Disease: Challenges and Pitfalls. Front Cardiovasc Med 2014; 1:13. [PMID: 26664863 PMCID: PMC4668858 DOI: 10.3389/fcvm.2014.00013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 12/07/2014] [Indexed: 01/15/2023] Open
Abstract
Coronary artery disease is the leading cause of mortality and morbidity in the chronic kidney disease (CKD) population and often presents with atypical symptoms. Current diagnostic investigations of myocardial ischemia in CKD lack sensitivity and specificity or may have adverse effects. We present a case vignette and explore the challenges of diagnostic myocardial stress investigation in patients with CKD.
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Affiliation(s)
- Susie F C Parnham
- Department of Cardiovascular Medicine, Flinders Medical Centre , Bedford Park, SA , Australia ; School of Medicine, Flinders University , Bedford Park, SA , Australia
| | - Jonathan M Gleadle
- School of Medicine, Flinders University , Bedford Park, SA , Australia ; Department of Renal Medicine, School of Medicine, Flinders University , Bedford Park, SA , Australia
| | - Carmine G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre , Bedford Park, SA , Australia ; School of Medicine, Flinders University , Bedford Park, SA , Australia
| | - Joseph B Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre , Bedford Park, SA , Australia ; School of Medicine, Flinders University , Bedford Park, SA , Australia
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22
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García-Orta R, Mahía-Casado P, Gómez de Diego JJ, Barba-Cosials J, Rodriguez-Palomares JF, Aguadé-Bruix S, Candell-Riera J. Novedades en imagen cardiaca 2013. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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23
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de Abreu JS, Lima JWO, Diógenes TCP, Siqueira JM, Pimentel NL, Gomes PS, de Abreu MEB, Paes JN. Coronary flow velocity reserve during dobutamine stress echocardiography. Arq Bras Cardiol 2014; 102:134-42. [PMID: 24676368 PMCID: PMC3987342 DOI: 10.5935/abc.20130242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/11/2013] [Accepted: 08/20/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND A coronary flow velocity reserve (CFVR)≥2 is adequate to infer a favorable prognosis or the absence of significant coronary artery disease. OBJECTIVE To identify parameters which are relevant to obtain CFVR (adequate or inadequate) in the left anterior descending coronary artery (LAD) during dobutamine stress echocardiography (DSE). METHODS 100 patients referred for detection of myocardial ischemia by DSE were evaluated; they were instructed to discontinue the use of β-blockers 72 hours prior to the test. CFVR was calculated as a ratio of the diastolic peak velocity (cm/s) (DPV) on DSE (DPV-DSE) to baseline DPV at rest (DPV-Rest). In group I, CFVR was <2 and, in group II, CFVR was ≥2. The Fisher's exact test and Student's t test were used for the statistical analyses. P values<0.05 were considered statistically significant. RESULTS At rest, the time (in seconds) to obtain Doppler in LAD in groups I and II was not different (53±31 vs. 45±32; p=0.23). During DSE, LAD was recorded in 92 patients. Group I patients were older (65.9±9.3 vs. 61.2±10.8 years; p=0.04), had lower ejection fraction (61±10 vs. 66±6%; p=0.005), higher DPV-Rest (36.81±08 vs. 25.63±06 cm/s; p<0.0001) and lower CFVR (1.67±0.24 vs. 2.53±0.57; p<0.0001), but no difference was observed regarding DPVDSE (61.40±16 vs. 64.23±16 cm/s; p=0.42). β-blocker discontinuation was associated with a 4-fold higher chance of a CFVR<2 (OR= 4; 95% CI [1.171-13.63], p=0.027). CONCLUSION DPV-Rest was the main parameter to determine an adequate CFVR. β-blocker discontinuation was significantly associated with inadequate CFVR. The high feasibility and the time to record the LAD corroborate the use of this methodology.
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Affiliation(s)
- José Sebastião de Abreu
- Prontocárdio - Pronto Atendimento Cardiológico SC Ltda, Fortaleza, CE -
Brazil
- Clinicárdio - JAC Métodos Diagnósticos SS, Fortaleza, CE - Brazil
- Faculdade de Medicina da Universidade Federal do Ceará, Fortaleza, CE -
Brazil
| | | | - Tereza Cristina Pinheiro Diógenes
- Prontocárdio - Pronto Atendimento Cardiológico SC Ltda, Fortaleza, CE -
Brazil
- Clinicárdio - JAC Métodos Diagnósticos SS, Fortaleza, CE - Brazil
| | | | | | - Pedro Sabino Gomes
- Faculdade de Medicina da Universidade Federal do Ceará, Fortaleza, CE -
Brazil
| | - Marília Esther Benevides de Abreu
- Prontocárdio - Pronto Atendimento Cardiológico SC Ltda, Fortaleza, CE -
Brazil
- Clinicárdio - JAC Métodos Diagnósticos SS, Fortaleza, CE - Brazil
| | - José Nogueira Paes
- Prontocárdio - Pronto Atendimento Cardiológico SC Ltda, Fortaleza, CE -
Brazil
- Clinicárdio - JAC Métodos Diagnósticos SS, Fortaleza, CE - Brazil
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García-Orta R, Mahía-Casado P, Gómez de Diego JJ, Barba-Cosials J, Rodriguez-Palomares JF, Aguadé-Bruix S, Candell-Riera J. Update on cardiac imaging techniques 2013. ACTA ACUST UNITED AC 2014; 67:127-34. [PMID: 24795120 DOI: 10.1016/j.rec.2013.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/02/2013] [Indexed: 11/29/2022]
Abstract
Cardiac imaging is a cornerstone of diagnosis in heart conditions, and an essential tool for assessing prognosis and establishing treatment decisions. This year, echocardiography stands out as a guide in interventional procedures and in choosing the size of the prosthesis. It is also proving to be a valuable technique in low-flow, low-gradient aortic stenosis. Three-dimensional echocardiography is advancing our knowledge of cardiac anatomy and valvular measurements. The parameters indicating tissue deformation have predictive power in valve disease and in the follow-up of drug-induced cardiotoxicity. Single-photon emission computed tomography and positron emission tomography are proving useful in ischemic heart disease and in the diagnosis of cardiac inflammation and infections. The role of computed tomography has been strengthened in noninvasive coronary angiography, the emergency room management of chest pain, assessment of chronic occlusions, and morphologic study of coronary plaque. Cardiac magnetic resonance imaging remains the gold standard for tissue characterization in ischemic heart disease and cardiomyopathies, and is assuming a greater role in stress studies and in the assessment of myocardial viability.
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Affiliation(s)
- Rocío García-Orta
- Servicio de Cardiología, Hospital Virgen de las Nieves, Granada, Spain.
| | | | | | - Joaquín Barba-Cosials
- Departamento de Cardiología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | | | | | - Jaume Candell-Riera
- Servicio de Medicina Nuclear, Hospital Vall d'Hebron, Barcelona, Spain; Servicio de Cardiología, Hospital Vall d'Hebron, Barcelona, Spain
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Zagatina A, Krylova L, Vareldzhan Y, Tyurina TV, Clitsenko O, Zhuravskaya N. Comparison of 5-Year Outcomes for Patients With Coronary Artery Disease in Groups With and Without Revascularization With Different Results of Stress Echocardiography. Cardiol Res 2013; 4:152-158. [PMID: 28352438 PMCID: PMC5358200 DOI: 10.4021/cr294e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2013] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND There is conflicting data in contemporary literature concerning the best way to treat patients with stable coronary artery disease; specifically, whether medical treatment alone or invasive strategies combined with medical treatment are better. The purpose of this study was to evaluate the clinical outcomes of patients with and without revascularization after stress echocardiography and to create formulas for detecting patients with a very high risk of cardiac death/major adverse cardiac event (MACE) in their present conditions. METHODS We assessed 323 patients (53.9 ± 8.4 years, 247 men), undergoing upright bicycle stress echocardiography in 2006 - 2007. During a median follow-up of 5.2 ± 0.2 years, 21 cardiovascular and 5 confirmed non-cardiac deaths occurred. Eighty-three patients underwent revascularization. RESULTS Stress echocardiography was normal in 32% and abnormal in 68%. All the patients with CAD were prescribed acetylsalicylic acid, statins, beta-blockers and ACE inhibitors. Eighty-seven percents of the patients took medication regularly. The percentage taking medication didn't significantly differ in the subgroups. Two formulas were created for detecting a very high risk of cardiac death (25%) or MACE (68%) within 5 years. All the patients with abnormal stress tests were divided into two subgroups: 80 patients with revascularization and 138 subjects without revascularization. There was a significant difference in 5 year cardiac mortality if the patients had an index of wall motion abnormality (IWMA) after exercise greater than or equal to 1.3. CONCLUSION It is possible to identify during stress echocardiography subjects with a very high risk for cardiac death/MACE. Patients with IWMA ≥ 1.3 had improved outcomes following revascularization.
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Affiliation(s)
| | - Ludmila Krylova
- Leningrad Regional Cardiologic Dispensary, St. Petersburg, Russian Federation
| | | | - Tatyana V Tyurina
- Leningrad Regional Cardiologic Dispensary, St. Petersburg, Russian Federation
| | - Olga Clitsenko
- Northwestern Medical University n.a. I.I. Mechnikov, St. Petersburg, Russian Federation
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Lipinski MJ, McVey CM, Berger JS, Kramer CM, Salerno M. Prognostic value of stress cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease: a systematic review and meta-analysis. J Am Coll Cardiol 2013; 62:826-38. [PMID: 23727209 DOI: 10.1016/j.jacc.2013.03.080] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 02/24/2013] [Accepted: 03/26/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study sought to perform a systematic review and meta-analysis to understand the role of stress cardiac magnetic resonance imaging (CMR) in assessing cardiovascular prognosis in patients with known or suspected coronary artery disease (CAD). BACKGROUND Although stress CMR is excellent for the diagnosis of obstructive CAD, the prognostic value of stress CMR has been less well described. METHODS PubMed, Cochrane CENTRAL, and metaRegister of Controlled Trials were searched for stress CMR studies with >6 months of prognostic data. Primary endpoints were cardiovascular death, myocardial infarction (MI), and a composite outcome of cardiovascular death or MI during follow-up. Summary effect estimates were generated with random-effects modeling, and annualized event rates were assessed. RESULTS Nineteen studies (14 vasodilator, 4 dobutamine, and 1 that used both) involved a total of 11,636 patients with a mean follow-up of 32 months. Patients had a mean age of 63 ± 12 years, 63% were male, and 26% had previous MI; mean left ventricular ejection fraction was 61 ± 12%; and late gadolinium enhancement was present in 29% and ischemia in 32%. Patients with ischemia had a higher incidence of MI (odds ratio [OR]: 7.7; p < 0.0001), cardiovascular death (OR: 7.0; p < 0.0001), and the combined endpoint (OR: 6.5; p < 0.0001) compared with those with a negative study. The combined outcome annualized events rates were 4.9% for a positive versus 0.8% for a negative stress CMR (p < 0.0001), 2.8% versus 0.3% for cardiovascular death (p < 0.0001), and 2.6% versus 0.4% for MI (p < 0.0005). The presence of late gadolinium enhancement was also significantly associated with a worse prognosis. CONCLUSIONS A negative stress CMR study is associated with very low risk of cardiovascular death and MI. Stress CMR has excellent prognostic characteristics and may help guide risk stratification of patients with known or suspected CAD.
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Affiliation(s)
- Michael J Lipinski
- Department of Medicine, Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Jaarsma C, Nagel E, Schalla S. A Critical Review of Different Imaging Methods for the Assessment of Myocardial Ischemia. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-012-9185-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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