1
|
Caullery B, Barone-Rochette G. Is coronary artery disease screening by imaging in patients with chronic kidney disease necessary? Arch Cardiovasc Dis 2024; 117:457-460. [PMID: 39209692 DOI: 10.1016/j.acvd.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/07/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Benoit Caullery
- Department of Cardiology, University Hospital, 38000 Grenoble, France
| | - Gilles Barone-Rochette
- Department of Cardiology, University Hospital, 38000 Grenoble, France; University Grenoble Alpes, INSERM, CHU Grenoble Alpes, LRB, 38000 Grenoble, France; French Clinical Research Infrastructure Network, 75018 Paris, France.
| |
Collapse
|
2
|
Huck DM, Divakaran S, Weber B, Brown JM, Lopez D, Souza ACDAH, Hainer J, Blankstein R, Dorbala S, Di Carli M. Comparative effectiveness of positron emission tomography and single-photon emission computed tomography myocardial perfusion imaging for predicting risk in patients with cardiometabolic disease. J Nucl Cardiol 2024:101908. [PMID: 38996910 DOI: 10.1016/j.nuclcard.2024.101908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 06/23/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND The epidemiology of coronary artery disease (CAD) has shifted, with increasing prevalence of cardiometabolic disease and decreasing findings of obstructive CAD on myocardial perfusion imaging (MPI). Coronary microvascular dysfunction (CMD), defined as impaired myocardial flow reserve (MFR) by positron emission tomography (PET), has emerged as a key mediator of risk. We aimed to assess whether PET MFR provides additive value for risk stratification of cardiometabolic disease patients compared with single-photon emission computed tomography (SPECT) MPI. METHODS We retrospectively followed patients referred for PET, exercise SPECT, or pharmacologic SPECT MPI with cardiometabolic disease (obesity, diabetes, or chronic kidney disease) and without known CAD. We compared rates and hazards of composite major adverse cardiovascular events (MACEs) (annualized cardiac mortality or acute myocardial infarction) among propensity-matched PET and SPECT patients using Poisson and Cox regression. Normal SPECT was defined as a total perfusion deficit (TPD) of <5%, reflecting the absence of obstructive CAD. Normal PET was defined as a TPD of <5% plus an MFR of ≥2.0. RESULTS Among 21,544 patients referred from 2006 to 2020, cardiometabolic disease was highly prevalent (PET: 2308 [67%], SPECT: 9984 [55%]) and higher among patients referred to PET (P < 0.001). Obstructive CAD findings (TPD > 5%) were uncommon (PET: 21% and SPECT: 11%). Conversely, impaired MFR on PET (<2.0) was common (62%). In a propensity-matched analysis over a median 6.4-year follow-up, normal PET identified low-risk (0.9%/year MACE) patients, and abnormal PET identified high-risk (4.2%/year MACE) patients with cardiometabolic disease; conversely, those with normal pharmacologic SPECT remained moderate-risk (1.6%/year, P < 0.001 compared to normal PET). CONCLUSIONS Cardiometabolic disease is common among patients referred for MPI and is associated with a heterogenous level of risk. Compared with pharmacologic SPECT, PET with MFR can detect nonobstructive CAD including CMD and can more accurately discriminate low-risk from higher-risk individuals.
Collapse
Affiliation(s)
- Daniel M Huck
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brittany Weber
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jenifer M Brown
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diana Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ana Carolina do A H Souza
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Valenta I, Schindler TH. PET-determined myocardial perfusion and flow in coronary artery disease characterization. J Med Imaging Radiat Sci 2024; 55:S44-S50. [PMID: 38403519 DOI: 10.1016/j.jmir.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/27/2024]
Abstract
Positron emission tomography (PET) myocardial perfusion imaging in conjunction with tracer-kinetic modeling enables the concurrent assessment of myocardial perfusion and regional myocardial blood flow (MBF) of the left ventricle in absolute terms in milliliters per gram per minute (mL/g/min). The non-invasive quantification of MBF during pharmacologically induced hyperemia, at rest, and corresponding myocardial flow reserve (MFR) opens a new avenue for the identification and characterization of classical or endogen type of coronary microvascular dysfunction (CMD) as functional substrate for microvascular angina in patients with non-obstructive coronary artery disease (CAD) and/or no CAD at all. Further, PET-MBF quantification expands the scope of conventional myocardial perfusion imaging from the identification of advanced, and flow-limiting, epicardial CAD to early stages of atherosclerosis and/or CMD. Adding MBF assessment to myocardial perfusion may also reliably unravel diffuse ischemia owing to significant left main stenosis and/or multivessel CAD, commonly confirmed by peak stress transient ischemic cavity dilation of the left ventricle during maximal vasomotor stress compared to rest on gated PET images. Owing to high spatial and contrast resolution in conjunction with photon-attenuation free myocardial perfusion PET images, PET is preferentially used for CAD detection in advanced obesity and women with pronounced breast habitus. With increasing clinical use of cardiac PET perfusion and MBF assessment, individualized, and image-guided cardiovascular treatment decisions in CAD patients is likely to ensue, while its translation into improved cardiovascular outcome remains to be investigated.
Collapse
Affiliation(s)
- Ines Valenta
- Washington University in St. Louis School of Medicine, Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, St. Louis, MO, USA
| | - Thomas H Schindler
- Washington University in St. Louis School of Medicine, Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, St. Louis, MO, USA.
| |
Collapse
|
4
|
Huck DM, Weber B, Schreiber B, Pandav J, Parks S, Hainer J, Brown JM, Divakaran S, Blankstein R, Dorbala S, Trinquart L, Chandraker A, Di Carli MF. Comparative Effectiveness of PET and SPECT MPI for Predicting Cardiovascular Events After Kidney Transplant. Circ Cardiovasc Imaging 2024; 17:e015858. [PMID: 38227694 PMCID: PMC10794031 DOI: 10.1161/circimaging.123.015858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Advanced chronic kidney disease is associated with high cardiovascular risk, even after kidney transplant. Pretransplant cardiac testing may identify patients who require additional assessment before transplant or would benefit from risk optimization. The objective of the current study was to determine the relative prognostic utility of pretransplant positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for posttransplant major adverse cardiovascular events (MACEs). METHODS We retrospectively followed patients who underwent MPI before kidney transplant for the occurrence of MACE after transplant including myocardial infarction, stroke, heart failure, and cardiac death. An abnormal MPI result was defined as a total perfusion deficit >5% of the myocardium. To determine associations of MPI results with MACE, we utilized Cox hazard regression with propensity weighting for PET versus SPECT with model factors, including demographics and cardiovascular risk factors. RESULTS A total of 393 patients underwent MPI (208 PET and 185 SPECT) and were followed for a median of 5.9 years post-transplant. Most were male (58%), median age was 58 years, and there was a high burden of hypertension (88%) and diabetes (33%). A minority had abnormal MPI (n=58, 15%). In propensity-weighted hazard regression, abnormal PET result was associated with posttransplant MACE (hazard ratio, 3.02 [95% CI, 1.78-5.11]; P<0.001), while there was insufficient evidence of an association of abnormal SPECT result with MACE (1.39 [95% CI, 0.72-2.66]; P=0.33). The explained relative risk of the PET result was higher than the SPECT result (R2 0.086 versus 0.007). Normal PET was associated with the lowest risk of MACE (2.2%/year versus 3.6%/year for normal SPECT; P<0.001). CONCLUSIONS Kidney transplant recipients are at high cardiovascular risk, despite a minority having obstructive coronary artery disease on MPI. PET MPI findings predict posttransplant MACE. Normal PET may better discriminate lower risk patients compared with normal SPECT, which should be confirmed in a larger prospective study.
Collapse
Affiliation(s)
- Daniel M Huck
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Weber
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Schreiber
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jay Pandav
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean Parks
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jon Hainer
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jenifer M Brown
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Divakaran
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharmila Dorbala
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (L.T.)
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA (L.T.)
| | - Anil Chandraker
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marcelo F Di Carli
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
5
|
Di Carli MF. Future of Radionuclide Myocardial Perfusion Imaging: Transitioning from SPECT to PET. J Nucl Med 2023; 64:3S-10S. [PMID: 37918841 DOI: 10.2967/jnumed.122.264864] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/05/2023] [Indexed: 11/04/2023] Open
Affiliation(s)
- Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
6
|
Hughes DL, Pan J, Answine AR, Sonnenday CJ, Waits SA, Kumar SS, Menees DS, Wanamaker B, Bhave NM, Tincopa MA, Fontana RJ, Sharma P. Positron emission tomography myocardial perfusion imaging (PET MPI) findings predictive of post-liver transplant major adverse cardiac events. Liver Transpl 2023; 29:970-978. [PMID: 36879556 DOI: 10.1097/lvt.0000000000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023]
Abstract
Positron emission tomography myocardial perfusion imaging (PET MPI) is a noninvasive diagnostic test capable of detecting coronary artery disease, structural heart disease, and myocardial flow reserve (MFR). We aimed to determine the prognostic utility of PET MPI to predict post-liver transplant (LT) major adverse cardiac events (MACE). Among the 215 LT candidates that completed PET MPI between 2015 and 2020, 84 underwent LT and had 4 biomarker variables of clinical interest on pre-LT PET MPI (summed stress and difference scores, resting left ventricular ejection fraction, global MFR). Post-LT MACE were defined as acute coronary syndrome, heart failure, sustained arrhythmia, or cardiac arrest within the first 12 months post-LT. Cox regression models were constructed to determine associations between PET MPI variable/s and post-LT MACE. The median LT recipient age was 58 years, 71% were male, 49% had NAFLD, 63% reported prior smoking, 51% had hypertension, and 38% had diabetes mellitus. A total of 20 MACE occurred in 16 patients (19%) at a median of 61.5 days post-LT. One-year survival of MACE patients was significantly lower than those without MACE (54% vs. 98%, p =0.001). On multivariate analysis, reduced global MFR ≤1.38 was associated with a higher risk of MACE [HR=3.42 (1.23-9.47), p =0.019], and every % reduction in left ventricular ejection fraction was associated with an 8.6% higher risk of MACE [HR=0.92 (0.86-0.98), p =0.012]. Nearly 20% of LT recipients experienced MACE within the first 12 months of LT. Reduced global MFR and reduced resting left ventricular ejection fraction on PET MPI among LT candidates were associated with increased risk of post-LT MACE. Awareness of these PET-MPI parameters may help improve cardiac risk stratification of LT candidates if confirmed in future studies.
Collapse
Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Jason Pan
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Adeline R Answine
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Seth A Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel S Menees
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brett Wanamaker
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicole M Bhave
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica A Tincopa
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
7
|
Ruddy TD, Tavoosi A, Taqueti VR. Role of nuclear cardiology in diagnosis and risk stratification of coronary microvascular disease. J Nucl Cardiol 2023; 30:1327-1340. [PMID: 35851643 DOI: 10.1007/s12350-022-03051-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/22/2022] [Indexed: 10/17/2022]
Abstract
Coronary flow reserve (CFR) with positron emission tomography/computed tomography (PET/CT) has an important role in the diagnosis of coronary microvascular disease (CMD), aids risk stratification and may be useful in monitoring therapy. CMD contributes to symptoms and a worse prognosis in patients with coronary artery disease (CAD), nonischemic cardiomyopathies, and heart failure. CFR measurements may improve our understanding of the role of CMD in symptoms and prognosis in CAD and other cardiovascular diseases. The clinical presentation of CAD has changed. The prevalence of nonobstructive CAD has increased to about 50% of patients with angina undergoing angiography. Ischemia with nonobstructive arteries (INOCA) is recognized as an important cause of symptoms and has an adverse prognosis. Patients with INOCA may have ischemia due to CMD, epicardial vasospasm or diffuse nonobstructive CAD. Reduced CFR in patients with INOCA identifies a high-risk group that may benefit from management strategies specific for CMD. Although measurement of CFR by PET/CT has excellent accuracy and repeatability, use is limited by cost and availability. CFR measurement with single-photon emission tomography (SPECT) is feasible, validated, and would increase availability and use of CFR. Patients with CMD can be identified by reduced CFR and selected for specific therapies.
Collapse
Affiliation(s)
- Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
| | - Anahita Tavoosi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Viviany R Taqueti
- Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Ye Z, An S, Gao Y, Xie E, Zhao X, Guo Z, Li Y, Shen N, Ren J, Zheng J. The prediction of in-hospital mortality in chronic kidney disease patients with coronary artery disease using machine learning models. Eur J Med Res 2023; 28:33. [PMID: 36653875 PMCID: PMC9847092 DOI: 10.1186/s40001-023-00995-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Chronic kidney disease (CKD) patients with coronary artery disease (CAD) in the intensive care unit (ICU) have higher in-hospital mortality and poorer prognosis than patients with either single condition. The objective of this study is to develop a novel model that can predict the in-hospital mortality of that kind of patient in the ICU using machine learning methods. METHODS Data of CKD patients with CAD were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Boruta algorithm was conducted for the feature selection process. Eight machine learning algorithms, such as logistic regression (LR), random forest (RF), Decision Tree, K-nearest neighbors (KNN), Gradient Boosting Decision Tree Machine (GBDT), Support Vector Machine (SVM), Neural Network (NN), and Extreme Gradient Boosting (XGBoost), were conducted to construct the predictive model for in-hospital mortality and performance was evaluated by average precision (AP) and area under the receiver operating characteristic curve (AUC). Shapley Additive Explanations (SHAP) algorithm was applied to explain the model visually. Moreover, data from the Telehealth Intensive Care Unit Collaborative Research Database (eICU-CRD) were acquired as an external validation set. RESULTS 3590 and 1657 CKD patients with CAD were acquired from MIMIC-IV and eICU-CRD databases, respectively. A total of 78 variables were selected for the machine learning model development process. Comparatively, GBDT had the highest predictive performance according to the results of AUC (0.946) and AP (0.778). The SHAP method reveals the top 20 factors based on the importance ranking. In addition, GBDT had good predictive value and a certain degree of clinical value in the external validation according to the AUC (0.865), AP (0.672), decision curve analysis, and calibration curve. CONCLUSION Machine learning algorithms, especially GBDT, can be reliable tools for accurately predicting the in-hospital mortality risk for CKD patients with CAD in the ICU. This contributed to providing optimal resource allocation and reducing in-hospital mortality by tailoring precise management and implementation of early interventions.
Collapse
Affiliation(s)
- Zixiang Ye
- grid.11135.370000 0001 2256 9319Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, 100029 China
| | - Shuoyan An
- grid.415954.80000 0004 1771 3349Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029 China
| | - Yanxiang Gao
- grid.415954.80000 0004 1771 3349Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029 China
| | - Enmin Xie
- grid.506261.60000 0001 0706 7839Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100029 China
| | - Xuecheng Zhao
- grid.415954.80000 0004 1771 3349Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029 China
| | - Ziyu Guo
- grid.11135.370000 0001 2256 9319Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, 100029 China
| | - Yike Li
- grid.506261.60000 0001 0706 7839Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100029 China
| | - Nan Shen
- grid.11135.370000 0001 2256 9319Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, 100029 China
| | - Jingyi Ren
- grid.415954.80000 0004 1771 3349Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029 China
| | - Jingang Zheng
- grid.11135.370000 0001 2256 9319Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, 100029 China ,grid.415954.80000 0004 1771 3349Department of Cardiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029 China
| |
Collapse
|
9
|
Hypertension and cardiomyopathy associated with chronic kidney disease: epidemiology, pathogenesis and treatment considerations. J Hum Hypertens 2023; 37:1-19. [PMID: 36138105 PMCID: PMC9831930 DOI: 10.1038/s41371-022-00751-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/09/2022] [Accepted: 08/31/2022] [Indexed: 01/31/2023]
Abstract
Chronic kidney disease (CKD) is a complex condition with a prevalence of 10-15% worldwide. An inverse-graded relationship exists between cardiovascular events and mortality with kidney function which is independent of age, sex, and other risk factors. The proportion of deaths due to heart failure and sudden cardiac death increase with progression of chronic kidney disease with relatively fewer deaths from atheromatous, vasculo-occlusive processes. This phenomenon can largely be explained by the increased prevalence of CKD-associated cardiomyopathy with worsening kidney function. The key features of CKD-associated cardiomyopathy are increased left ventricular mass and left ventricular hypertrophy, diastolic and systolic left ventricular dysfunction, and profound cardiac fibrosis on histology. While these features have predominantly been described in patients with advanced kidney disease on dialysis treatment, patients with only mild to moderate renal impairment already exhibit structural and functional changes consistent with CKD-associated cardiomyopathy. In this review we discuss the key drivers of CKD-associated cardiomyopathy and the key role of hypertension in its pathogenesis. We also evaluate existing, as well as developing therapies in the treatment of CKD-associated cardiomyopathy.
Collapse
|
10
|
Golzar Y, Doukky R. Perioperative cardiac risk assessment in kidney transplantation: It's time to search for a new gold standard. J Nucl Cardiol 2022; 29:3416-3418. [PMID: 34036530 DOI: 10.1007/s12350-021-02673-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Yasmeen Golzar
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
| |
Collapse
|
11
|
Improving Detection of CAD and Prognosis with PET/CT Quantitative Absolute Myocardial Blood Flow Measurements. Curr Cardiol Rep 2022; 24:1855-1864. [PMID: 36348147 DOI: 10.1007/s11886-022-01805-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of the role of PET MPI in the detection of CAD, focussing on the added value of MBF for diagnosis and prognostication. RECENT FINDINGS Positron emission tomography (PET) myocardial perfusion imaging (MPI) is increasingly used for the risk stratification of patients with suspected or established coronary artery disease (CAD). PET MPI provides accurate and reproducible non-invasive quantification of myocardial blood flow (MBF) at rest and during hyperemia, providing incremental information over conventional myocardial perfusion alone. Inclusion of MBF in PET MPI interpretation improves both its sensitivity and specificity. Moreover, quantitative MBF measurements have repeatedly been shown to offer incremental and independent prognostic information over conventional clinical markers in a broad range of conditions, including in CAD. Quantitative MBF measurement is now an established and powerful tool enabling accurate risk stratification and guiding patients' management. The role of PET MPI and flow quantification in cardiac allograft vasculopathy (CAV), which represents a particular form of CAD, will also be reviewed.
Collapse
|
12
|
Park S, Lee SH, Shin D, Hong D, Joh HS, Choi KH, Kim HK, Ha SJ, Park TK, Yang JH, Song YB, Hahn JY, Choi SH, Gwon HC, Lee JM. Prognostic Impact of Coronary Flow Reserve in Patients With CKD. Kidney Int Rep 2022; 8:64-74. [PMID: 36644355 PMCID: PMC9832048 DOI: 10.1016/j.ekir.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/24/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Both coronary flow reserve (CFR) and chronic kidney disease (CKD) are known to be associated with adverse cardiac events. However, it is unclear how these prognostic factors are interrelated. This study evaluated the association between intracoronary physiologic indexes and CKD and their prognostic implications. Methods A total of 351 patients without left ventricular systolic dysfunction (ejection fraction ≥ 40%) and not on dialysis whose revascularization was deferred based on fractional flow reserve (FFR) > 0.80 were analyzed. Depressed CFR was defined as CFR ≤ 2.0. The primary outcome was a composite of cardiac death or hospitalization for heart failure at 3 years. Results Patients with CKD showed lower CFR than the non-CKD population (3.28 ± 1.77 vs. 2.60 ± 1.09, P < 0.001), mainly driven by increased resting coronary flow. There was no significant difference in hyperemic coronary flow, FFR, and index of microvascular resistance between the 2 groups. CFR was significantly associated with estimated glomerular filtration rate (eGFR) (P = 0.045), and the proportion of depressed CFR was significantly increased with higher CKD stages (P = 0.011). The risk of cardiac death or hospitalization for heart failure was the lowest in the non-CKD and preserved CFR group (11.9%) and the highest in the CKD and depressed CFR group (60.0%, overall log rank P < 0.001). Both CKD (adjusted hazard ratio [HRadj] 2.614, 95% confidence interval [CI] 1.505-4.539, P < 0.001) and depressed CFR (HRadj 3.237, 95% CI 2.015-5.199, P < 0.001) were independently associated with the risk of the primary outcome. Conclusion There was a significant association between severity of CKD and CFR. Both CKD and depressed CFR showed independent association with higher risk of cardiac death or hospitalization for heart failure.
Collapse
Affiliation(s)
- Sugeon Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Hun Lee
- Department of Internal Medicine and Cardiovascular Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David Hong
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Sung Joh
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Republic of Korea
| | - Sang Jin Ha
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,Correspondence: Joo Myung Lee, Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea.
| |
Collapse
|
13
|
Jain V, Gupta K, Bhatia K, Rajapreyar I, Singh A, Zhou W, Klein A, Nanda NC, Prabhu SD, Bajaj NS. Coronary flow abnormalities in chronic kidney disease: A systematic review and meta-analysis. Echocardiography 2022; 39:1382-1390. [PMID: 36198077 DOI: 10.1111/echo.15445] [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: 04/09/2022] [Revised: 07/10/2022] [Accepted: 08/15/2022] [Indexed: 10/10/2022] Open
Abstract
BACKGROUND Coronary vasomotion abnormalities have been described in small studies but not studied systematically. We aimed to review the present literature and analyze it to improve our understanding of chronic kidney disease (CKD) related-coronary microvascular dysfunction. OBJECTIVE Coronary flow reserve (CFR) is a well-known measure of coronary vasomotion. We aimed to assess the difference in CFR among participants with and without CKD. METHODS PubMed, Embase, and Cochrane CENTRAL were systematically reviewed to identify studies that compared CFR in participants with and without CKD. We estimated standardized mean differences in mean CFR reported in these studies. We performed subgroup analyses according to imaging modality, and the presence of significant epicardial coronary artery disease. RESULTS In 14 observational studies with 5966 and 1410 patients with and without CKD, the mean estimated glomerular filtration rate (eGFR) was 29 ± 04 and 87 ± 25 ml/min/1.73 m2 , respectively. Mean CFR was consistently lower in patients with CKD in all studies and the cumulative mean difference was statistically significant (2.1 ± .3 vs. 2.7 ± .5, standardized mean difference -.8, 95% CI -1.1, -.6, p < .05). The lower mean CFR was driven by both significantly higher mean resting flow velocity (.58 cm/s, 95% CI .17, .98) and lower mean stress flow velocity (-.94 cm/s, 95% CI -1.75, -.13) in studies with CKD. This difference remained significant across diagnostic modalities and even in absence of epicardial coronary artery disease. In meta-regression, there was a significant positive relationship between mean eGFR and mean CFR (p < .05). CONCLUSION Patients with CKD have a significantly lower CFR versus those without CKD, even in absence of epicardial coronary artery disease. There is a linear association between eGFR and CFR. Future studies are required to understand the mechanisms and therapeutic implications of these findings. KEY POINTS In this meta-analysis of observational studies, there was a significant reduction in coronary flow reserve in studies with chronic kidney disease versus those without. This difference was seen even in absence of epicardial coronary artery disease. In meta-regression, a lower estimate glomerular filtration rate was a significant predictor of lower coronary flow reserve. Coronary microvascular dysfunction, rather than atherosclerosis-related epicardial disease may underly increase cardiovascular risk in a patient with chronic kidney disease.
Collapse
Affiliation(s)
- Vardhmaan Jain
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kartik Gupta
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kirtipal Bhatia
- Department of Cardiology, Icahn School of Medicine at Mount Sinai (Morningside), New York, USA
| | - Indranee Rajapreyar
- Advanced Heart failure and Transplantation Center, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Amitoj Singh
- Division of Cardiology, University of Arizona College of Medicine-Tucson, Arizona, USA
| | - Wunan Zhou
- National Institute of Health, Bethesda, Maryland, USA
| | - Allan Klein
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Navin C Nanda
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sumanth D Prabhu
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Asheville Cardiology Associates, Asheville, North Carolina, USA
| |
Collapse
|
14
|
Ohashi H, Nawano T, Takashima H, Ando H, Goto R, Suzuki A, Sakurai S, Suzuki W, Nakano Y, Sawada H, Fujimoto M, Sakai K, Suzuki Y, Waseda K, Amano T. Differential Impact of Renal Function on the Diagnostic Performance of Resting Full-Cycle Ratio in Patients With Renal Dysfunction. Circ Rep 2022; 4:439-446. [PMID: 36120484 PMCID: PMC9437472 DOI: 10.1253/circrep.cr-22-0069] [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: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 01/10/2023] Open
Abstract
Background: Physiological assessments using fractional flow reserve (FFR) and resting full-cycle ratio (RFR) have been recommended for revascularization decision making. Previous studies have shown a 20% rate of discordance between FFR and RFR. In this context, the correlation between RFR and FFR in patients with renal dysfunction remains unclear. This study examined correlations between RFR and FFR according to renal function. Methods and Results: In all, 263 consecutive patients with 370 intermediate lesions were enrolled in the study. Patients were classified into 3 groups according to renal function: Group 1, estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2; Group 2, 30 mL/min/1.73 m2≤eGFR<60 mL/min/1.73 m2; Group 3, eGFR <30 mL/min/1.73 m2. The discordance between FFR and RFR was assessed using known cut-off values for FFR (≤0.80) and RFR (≤0.89). Of the 370 lesions, functional significance with FFR was observed in 154 (41.6%). RFR was significantly correlated with FFR in all groups (Group 1, R2=0.62 [P<0.001]; Group 2, R2=0.67 [P<0.001]; Group 3, R2=0.46 [P<0.001]). The rate of discordance between RFR and FFR differed significantly among the 3 groups (Group 1, 18.8%; Group 2, 18.5%; Group 3, 42.9%; P=0.02). Conclusions: The diagnostic performance of RFR differed based on renal function. A better understanding of the clinical factors contributing to FFR/RFR discordance, such as renal function, may facilitate the use of these indices.
Collapse
Affiliation(s)
| | | | | | | | - Reiji Goto
- Department of Cardiology, Aichi Medical University
| | | | | | | | | | | | | | - Koshiro Sakai
- Department of Medicine, Division of Cardiology, Showa University School of Medicine
| | | | | | | |
Collapse
|
15
|
Zhan J, Zhong L, Wu J. Assessment and Treatment for Coronary Microvascular Dysfunction by Contrast Enhanced Ultrasound. Front Cardiovasc Med 2022; 9:899099. [PMID: 35795368 PMCID: PMC9251174 DOI: 10.3389/fcvm.2022.899099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
With growing evidence in clinical practice, the understanding of coronary syndromes has gradually evolved out of focusing on the well-established link between stenosis of epicardial coronary artery and myocardial ischemia to the structural and functional abnormalities at the level of coronary microcirculation, known as coronary microvascular dysfunction (CMD). CMD encompasses several pathophysiological mechanisms of coronary microcirculation and is considered as an important cause of myocardial ischemia in patients with angina symptoms without obstructive coronary artery disease (CAD). As a result of growing knowledge of the understanding of CMD assessed by multiple non-invasive modalities, CMD has also been found to be involved in other cardiovascular diseases, including primary cardiomyopathies as well as heart failure with preserved ejection fraction (HFpEF). In the past 2 decades, almost all the imaging modalities have been used to non-invasively quantify myocardial blood flow (MBF) and promote a better understanding of CMD. Myocardial contrast echocardiography (MCE) is a breakthrough as a non-invasive technique, which enables assessment of myocardial perfusion and quantification of MBF, exhibiting promising diagnostic performances that were comparable to other non-invasive techniques. With unique advantages over other non-invasive techniques, MCE has gradually developed into a novel modality for assessment of the coronary microvasculature, which may provide novel insights into the pathophysiological role of CMD in different clinical conditions. Moreover, the sonothrombolysis and the application of artificial intelligence (AI) will offer the opportunity to extend the use of contrast ultrasound theragnostics.
Collapse
|
16
|
Kassab K, Doukky R. Cardiac imaging for the assessment of patients being evaluated for kidney transplantation. J Nucl Cardiol 2022; 29:543-557. [PMID: 33666870 DOI: 10.1007/s12350-021-02561-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/27/2021] [Indexed: 12/20/2022]
Abstract
Cardiac risk assessment before kidney transplantation has become widely accepted. However, the optimal patient selection and screening tool for cardiac assessment remain controversial. Clinicians face several challenges in this process, including the ever-growing pre-transplant population, aging transplant candidates, increasing prevalence of coronary artery disease, and scarcity of donor organs. Optimizing the cardiovascular risk profile in kidney transplant candidates is necessary to better appropriate limited donor organs and improve patient outcomes. Increasing waiting times from the initial evaluation for transplant candidacy to the actual transplant raises questions regarding re-testing and re-stratification of risk. In this review, we summarize and discuss the current literature on cardiac evaluation prior to kidney transplantation. We also propose simple evidence-based evaluation algorithms for initial and follow-up CAD surveillance in patients being wait-listed for kidney transplantation.
Collapse
Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Suite 3620, Chicago, IL, 60612, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison St., Suite 3620, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
| |
Collapse
|
17
|
Nakano S, Kohsaka S, Chikamori T, Fukushima K, Kobayashi Y, Kozuma K, Manabe S, Matsuo H, Nakamura M, Ohno T, Sawano M, Toda K, Ueda Y, Yokoi H, Gatate Y, Kasai T, Kawase Y, Matsumoto N, Mori H, Nakazato R, Niimi N, Saito Y, Shintani A, Watanabe I, Watanabe Y, Ikari Y, Jinzaki M, Kosuge M, Nakajima K, Kimura T. JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease. Circ J 2022; 86:882-915. [DOI: 10.1253/circj.cj-21-1041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shintaro Nakano
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Kenji Fukushima
- Department of Radiology and Nuclear Medicine, Fukushima Medical University
| | | | - Ken Kozuma
- Cardiology, Teikyo University School of Medicine
| | - Susumu Manabe
- Cardiac Surgery, International University of Health and Welfare Mita Hospital
| | | | - Masato Nakamura
- Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | | | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | - Hiroyoshi Yokoi
- Cardiovascular Center, International University of Health and Welfare Fukuoka Sanno Hospital
| | - Yodo Gatate
- Cardiology, Self-Defense Forces Central Hospital
| | | | | | | | - Hitoshi Mori
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Yuichi Saito
- Cardiovascular Medicine, Chiba University School of Medicine
| | - Ayumi Shintani
- Medical Statistics, Osaka City University Graduate School of Medicine
| | - Ippei Watanabe
- Cardiovascular Medicine, Toho University School of Medicine
| | | | - Yuji Ikari
- Cardiology, Tokai University School of Medicine
| | | | | | - Kenichi Nakajima
- Functional Imaging and Artificial Intelligence, Kanazawa University
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | |
Collapse
|
18
|
Bainey KR, Fleg JL, Hochman JS, Kunichoff DF, Anthopolos R, Chernyavskiy AM, Demkow M, Lopez-Quijano JM, Escobedo J, Poh KK, Ramos RB, Lima EG, Schuchlenz H, Ali ZA, Stone GW, Maron DJ, O'Brien SM, Spertus JA, Bangalore S. Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia. Am Heart J 2022; 243:187-200. [PMID: 34582775 PMCID: PMC10627379 DOI: 10.1016/j.ahj.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). METHODS Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. RESULTS Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. CONCLUSION Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.
Collapse
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Jerome L Fleg
- National Heart Lung and Blood Institute, Bethesda, MD
| | | | | | | | - Alexander M Chernyavskiy
- E.Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Novosibirsk, Russia
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Kian Keong Poh
- National University Heart Center Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Herwig Schuchlenz
- oLKH Graz II, Department fuer Kardiologie und Intensivmedizin, Graz, Austria
| | - Ziad A Ali
- Cardiovascular Research Foundation, New York, NY; Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY; St Francis Hospital, Roslyn, NY
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA
| | - Sean M O'Brien
- Duke Clinical Research Institute and Duke University, Durham, NC
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City (UMKC), Kansas City, MO
| | | |
Collapse
|
19
|
Groarke JD, Divakaran S, Nohria A, Killoran JH, Dorbala S, Dunne RM, Hainer J, Taqueti VR, Blankstein R, Mamon HJ, Di Carli MF. Coronary vasomotor dysfunction in cancer survivors treated with thoracic irradiation. J Nucl Cardiol 2021; 28:2976-2987. [PMID: 32691348 PMCID: PMC7855471 DOI: 10.1007/s12350-020-02255-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND We sought to test the hypothesis that thoracic radiation therapy (RT) is associated with impaired myocardial flow reserve (MFR), a measure of coronary vasomotor dysfunction. METHODS We retrospectively studied thirty-five consecutive patients (71% female, mean ± standard deviation (SD) age: 66 ± 11 years) referred clinically for positron emission tomography/computed tomography (PET/CT) myocardial perfusion imaging at a median (interquartile range, IQR) interval of 4.3 (2.1, 9.7) years following RT for a variety of malignancies. Radiation dose-volume histograms were generated for the heart and coronary arteries for each patient. RESULTS The median (IQR) of mean cardiac radiation doses was 12.0 (1.2, 24.2) Gray. There were significant inverse correlations between mean radiation dose and global MFR (MFRGlobal) and MFR in the left anterior descending artery territory (MFRLAD): Pearson's correlation coefficient = - .37 (P = .03) and - .38 (P = .03), respectively. For every one Gray increase in mean cardiac radiation dose, there was a mean ± standard error decrease of .02 ± .01 in MFRGlobal (P = .04) and MFRLAD (P = .03) after adjustment. CONCLUSIONS In patients with a history of RT clinically referred for cardiac stress PET, we found an inverse correlation between mean cardiac radiation dose and coronary vasomotor function.
Collapse
Affiliation(s)
- John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Killoran
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ruth M Dunne
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
20
|
Wenning C, Vrachimis A, Pavenstädt HJ, Reuter S, Schäfers M. Coronary artery calcium burden, carotid atherosclerotic plaque burden, and myocardial blood flow in patients with end-stage renal disease: A non-invasive imaging study combining PET/CT and 3D ultrasound. J Nucl Cardiol 2021; 28:2660-2670. [PMID: 32140994 PMCID: PMC8709813 DOI: 10.1007/s12350-020-02080-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/23/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Imaging-based measures of atherosclerosis such as coronary artery calcium score (CACS) and coronary flow reserve (CFR) as well as carotid atherosclerotic plaque burden (cPB) are predictors of cardiovascular events in the general population. The objective of this study was to correlate CACS, cPB, myocardial blood flow (MBF), and CFR in patients with end-stage renal disease (ESRD). METHODS AND RESULTS 39 patients (mean age 53 ± 12 years) with ESRD prior to kidney transplantation were enrolled. MBF and CFR were quantified at baseline and under hyperemia by 13N-NH3-PET/CT. CACS was calculated from low-dose CT scans acquired for PET attenuation correction. cPB was assessed by 3D ultrasound. Uni- and multivariate regression analyses between these and clinical parameters were performed. Median follow-up time for clinical events was 4.4 years. Kaplan-Meier survival estimates with log-rank test were performed with regards to cardiovascular (CV) events and death of any cause. CACS and cPB were associated in ESRD patients (r = 0.48; p ≤ 0.01). While cPB correlated with age (r = 0.43; p < 0.01), CACS did not. MBFstress was negatively associated with age (r = 0.44; p < 0.01) and time on dialysis (r = 0.42; p < 0.01). There were negative correlations between MBFstress and CACS (r = - 0.62; p < 0.001) and between MBFstress and cPB (r = - 0.43; p < 0.01). Age and CACS were the strongest predictors for MBFstress. CFR was impaired (< 2.0) in eight patients who also presented with higher cPB and higher CACS compared to those with a CFR > 2.0 (p = 0.06 and p = 0.4). In contrast to MBFstress, there was neither a significant correlation between CFR and CACS (r = - 0.2; p = 0.91) nor between CFR and cPB (r = - 0.1; p = 0.55). CV event-free survival was associated with reduced CFR and MBFstress (p = 0.001 and p < 0.001) but not with cPB or CACS. CONCLUSIONS CACS, cPB, and MBFstress are associated in patients with ESRD. Atherosclerosis is earlier detected by MBFstress than by CFR. CV event-free survival is associated with impaired CFR and MBFstress.
Collapse
Affiliation(s)
- Christian Wenning
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Alexis Vrachimis
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Hermann-Joseph Pavenstädt
- Department of Internal Medicine D, General Internal Medicine and Nephrology, University Hospital Münster, Münster, Germany
| | - Stefan Reuter
- Department of Internal Medicine D, General Internal Medicine and Nephrology, University Hospital Münster, Münster, Germany
| | - Michael Schäfers
- Department of Nuclear Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
- European Institute for Molecular Imaging (EIMI), University of Münster, Münster, Germany
- DFG EXC 1003 Cluster of Excellence 'Cells in Motion', University of Münster, Münster, Germany
| |
Collapse
|
21
|
Peix A. Choosing between anatomy and function is not always evident for the heart of end-stage renal disease patients. How low can we go? J Nucl Cardiol 2021; 28:2671-2675. [PMID: 32342299 DOI: 10.1007/s12350-020-02118-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
Patients with chronic kidney disease (CKD) are at a very high risk of adverse cardiovascular events. In CKD patients, vascular calcification is more prevalent, appears at an earlier age, and is more severe than in the general population. CKD physiology rather than the effects of dialysis is the primary driver of microvascular disease in these patients. Considering the significant morbidity and mortality attributable to cardiovascular disease in the CKD population, risk stratification remains an important challenge. Topics such as function vs anatomy to properly risk stratify these patients, as well as future perspectives on non-invasive techniques, will be addressed.
Collapse
Affiliation(s)
- Amalia Peix
- Nuclear Medicine Department, Institute of Cardiology, 17 No. 702, Vedado, CP 10 400, La Habana, Cuba.
| |
Collapse
|
22
|
Xiao F, Zhang W, He YN, Yang J, Liu X, Wang L, Zhang J, Dai H. Impaired perfusion in the myocardial microcirculation in asymptomatic patients with Stages 1-4 chronic kidney disease with intrarenal arterial lesions. Nephrol Dial Transplant 2021; 36:2066-2075. [PMID: 33877359 DOI: 10.1093/ndt/gfaa245] [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: 01/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Even mild renal disease is a powerful cardiovascular risk factor. However, the association between these pathophysiologic processes (especially in the early asymptomatic stage) is not known. METHODS We recruited 243 asymptomatic patients with Stages 1-4 chronic kidney disease (CKD) without obstructive coronary artery disease (CAD). We distinguished different degrees of severity of intrarenal arterial lesions (IALs) according to the Oxford classification. Myocardial microcirculation perfusion was measured using single-photon emission computed tomography (SPECT). Summed scores of 17 stress and rest image segments produced the summed stress score (SSS) and summed rest score (SRS), respectively. The summed difference score (SDS) was calculated as the difference between the SSS and SRS. Coronary microvascular disease (CMD) was defined as abnormal SPECT (SSS ≥4 or SDS ≥2) in the absence of obstructive CAD. RESULTS Participants showed a stepwise increase in CMD severity with IAL aggravation. SSS of no/mild/moderate/severe IALs was 1.64 ± 1.08, 2.56 ± 1.35, 4.42 ± 2.17 and 6.48 ± 3.52, respectively (P < 0.05 for all). SDS of no/mild/moderate/severe IALs was 1.29 ± 0.49, 1.75 ± 0.56, 3.06 ± 1.12 and 4.16 ± 1.85, respectively (P < 0.05 for all). The percentage of subclinical CMD in CKD patients with IALs was significantly higher than in those without IALs (69.57% versus 14.71%; P = 0.01). Multiple regression analysis showed that renal arteriolar hyalinization (odds ratio = 1.578, P = 0.009) was associated independently with subclinical CMD. CONCLUSIONS We demonstrated, for the first time, that impaired perfusion in the myocardial microcirculation in asymptomatic patients with Stages 1-4 CKD with IALs. Renal arteriolar hyalinization may be a useful marker of CMD in CKD.
Collapse
Affiliation(s)
- Fei Xiao
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Weiwei Zhang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Ya-Ni He
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jie Yang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Xinghong Liu
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Ling Wang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jianguo Zhang
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Huanzi Dai
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| |
Collapse
|
23
|
Pelletier-Galarneau M, Ruddy TD. A big step towards clinical implementation of myocardial blood flow quantification with CZT SPECT. J Nucl Cardiol 2021; 28:1487-1489. [PMID: 31535294 DOI: 10.1007/s12350-019-01894-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Matthieu Pelletier-Galarneau
- Department of Medical Imaging, Montreal Heart Institute, Montreal, QC, Canada
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
| |
Collapse
|
24
|
Bjerre KP, Clemmensen TS, Poulsen SH, Hvas AM, Løgstrup BB, Grove EL, Flyvholm F, Kristensen SD, Eiskjær H. Coronary Flow Velocity Reserve and Myocardial Deformation Predict Long-Term Outcomes in Heart Transplant Recipients. J Am Soc Echocardiogr 2021; 34:1294-1302. [PMID: 34325007 DOI: 10.1016/j.echo.2021.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND After heart transplantation (HTx), invasive coronary angiography is the gold standard for surveillance of cardiac allograft vasculopathy (CAV). Noninvasive CAV surveillance is desirable. The authors examined left ventricular global longitudinal strain (LVGLS) and noninvasive coronary flow velocity reserve (CFVR) related to CAV and prognosis after HTx. METHODS Doppler echocardiographic CFVR and LVGLS were evaluated in 98 HTx patients. All-cause mortality and major adverse cardiac events (MACE), including hospitalization for heart failure, cardiovascular death, and significant CAV progression, were recorded. RESULTS Median follow-up duration was 3.3 years (range: 1.7-5.4 years). Patients with low CFVR (<2.0; n = 20) showed reduced MACE-free survival (hazard ratio, 4.3; 95% CI, 2.2-8.4; P < .0001) and increased all-cause mortality (hazard ratio: 4.7; 95% CI: 2.0-11.3; P < .0001) compared with patients with high CFVR (≥2.0; n = 78). Worsened LVGLS (≥-15.5%) was also a strong independent predictor of MACE and cardiovascular and all-cause mortality. Combined low CFVR and worsened LVGLS provided incremental prognostic value, even after adjustment for CAV and time since HTx. The prevalence of low CFVR increased significantly with CAV severity, and the prevalence of combined low CFVR and/or worsened LVGLS was high in patients with moderate CAV (86%) and those with severe CAV (83%). The negative predictive value of combined high CFVR and improved LVGLS to rule out significant CAV was 94.5% (95% CI, 86.2%-98.4%), whereas the positive predictive value was 39.0% (95% CI, 25.3%-54.3%). The model had sensitivity of 84.2% (95% CI, 63.6%-95.3%) and specificity of 67.5% (95% CI, 56.6%-77.2%) for one or more abnormal parameters. CONCLUSIONS In HTx patients with severe CAV, a higher prevalence of low CFVR and worsened LVGLS was observed. Both measurements were strong independent predictors of MACE and all-cause mortality in HTx patients. Combined CFVR and LVGLS provided incremental prognostic value and showed an excellent ability to rule out significant CAV and may be considered as part of routine CAV surveillance of HTx patients.
Collapse
Affiliation(s)
- Kamilla P Bjerre
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Tor S Clemmensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen H Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Brian B Løgstrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Frederik Flyvholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen D Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| |
Collapse
|
25
|
Shajahan S, Amin J, Phillips JK, Hildreth CM. Relationship between sex and cardiovascular mortality in chronic kidney disease: A systematic review and meta-analysis. PLoS One 2021; 16:e0254554. [PMID: 34252153 PMCID: PMC8274915 DOI: 10.1371/journal.pone.0254554] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 06/28/2021] [Indexed: 01/29/2023] Open
Abstract
Chronic kidney disease (CKD) is a significant health challenge associated with high cardiovascular mortality risk. Historically, cardiovascular mortality risk has been found to higher in men than women in the general population. However, recent research has highlighted that this risk may be similar or even higher in women than men in the CKD population. To address the inconclusive and inconsistent evidence regarding this relationship between sex and cardiovascular mortality within CKD patients, a systematic review and meta-analysis of articles published between January 2004 and October 2020 using PubMed/Medline, EMBASE, Scopus and Cochrane databases was performed. Forty-eight studies were included that reported cardiovascular mortality among adult men relative to women with 95% confidence intervals (CI) or provided sufficient data to calculate risk estimates (RE). Random effects meta-analysis of reported and calculated estimates revealed that male sex was associated with elevated cardiovascular mortality in CKD patients (RE 1.13, CI 1.03-1.25). Subsequent subgroup analyses indicated higher risk in men in studies based in the USA and in men receiving haemodialysis or with non-dialysis-dependent CKD. Though men showed overall higher cardiovascular mortality risk than women, the increased risk was marginal, and appropriate risk awareness is necessary for both sexes with CKD. Further research is needed to understand the impact of treatment modality and geographical distribution on sex differences in cardiovascular mortality in CKD.
Collapse
Affiliation(s)
- Sultana Shajahan
- Department of Biomedical Science, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- Department of Health Systems and Populations, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Janaki Amin
- Department of Health Systems and Populations, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jacqueline K. Phillips
- Department of Biomedical Science, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Cara M. Hildreth
- Department of Biomedical Science, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| |
Collapse
|
26
|
Karimi Galougahi K, Chadban S, Mehran R, Bangalore S, Chertow GM, Ali ZA. Invasive Management of Coronary Artery Disease in Advanced Renal Disease. Kidney Int Rep 2021; 6:1513-1524. [PMID: 34169192 PMCID: PMC8207307 DOI: 10.1016/j.ekir.2021.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 12/19/2022] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in chronic kidney disease (CKD). CKD modifies the effects of traditional risk factors on atherosclerosis, with CKD-specific mechanisms, such as inflammation and altered mineral metabolism, playing a dominant pathophysiological role as kidney function declines. Traditional risk models and cardiovascular screening tests perform relatively poorly in the CKD population, and medical treatments including lipid-lowering therapies have reduced efficacy. Clinical presentation of cardiac ischemia in CKD is atypical, whereas invasive therapies are associated with higher rates of complications than in with patients with normal or near normal kidney function. The main focus of the present review is on the invasive approach to management of CAD in late-stage CKD, with an in-depth discussion of the findings of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA)-CKD trial, and their implications for therapeutic approach and future research in this area. We also briefly discuss the existing evidence in the epidemiology, pathogenesis, diagnosis, and medical management of CAD in late-stage CKD, end-stage kidney disease (ESKD), and kidney transplant recipients. We enumerate the evidence gap left by the frequent exclusion of patients with CKD from randomized controlled trials and highlight the priority areas for future research in the CKD population.
Collapse
Affiliation(s)
- Keyvan Karimi Galougahi
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Heart Research Institute, Sydney, Australia
| | - Steven Chadban
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Nephrology, Royal Prince Alfred Hospital, Sydney, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Australia
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sripal Bangalore
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University, Stanford, California, USA
| | - Ziad A. Ali
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
- Center for Interventional Vascular Therapy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
- The Heart Center, St. Francis Hospital, Roslyn, New York, USA
| |
Collapse
|
27
|
Radhakrishnan A, Pickup LC, Price AM, Law JP, McGee KC, Fabritz L, Senior R, Steeds RP, Ferro CJ, Townend JN. Coronary microvascular dysfunction is associated with degree of anaemia in end-stage renal disease. BMC Cardiovasc Disord 2021; 21:211. [PMID: 33902440 PMCID: PMC8074270 DOI: 10.1186/s12872-021-02025-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is common in end-stage renal disease (ESRD) and is an adverse prognostic marker. Coronary flow velocity reserve (CFVR) is a measure of coronary microvascular function and can be assessed using Doppler echocardiography. Reduced CFVR in ESRD has been attributed to factors such as diabetes, hypertension and left ventricular hypertrophy. The contributory role of other mediators important in the development of cardiovascular disease in ESRD has not been studied. The aim of this study was to examine the prevalence of CMD in a cohort of kidney transplant candidates and to look for associations of CMD with markers of anaemia, bone mineral metabolism and chronic inflammation. METHODS Twenty-two kidney transplant candidates with ESRD were studied with myocardial contrast echocardiography, Doppler CFVR assessment and serum multiplex immunoassay analysis. Individuals with diabetes, uncontrolled hypertension or ischaemic heart disease were excluded. RESULTS 7/22 subjects had CMD (defined as CFVR < 2). Demographic, laboratory and echocardiographic parameters and serum biomarkers were similar between subjects with and without CMD. Subjects with CMD had significantly lower haemoglobin than subjects without CMD (102 g/L ± 12 vs. 117 g/L ± 11, p = 0.008). There was a positive correlation between haemoglobin and CFVR (r = 0.7, p = 0.001). Similar results were seen for haematocrit. In regression analyses, haemoglobin was an independent predictor of CFVR (β = 0.041 95% confidence interval 0.012-0.071, p = 0.009) and of CFVR < 2 (odds ratio 0.85 95% confidence interval 0.74-0.98, p = 0.022). CONCLUSIONS Among kidney transplant candidates with ESRD, there is a high prevalence of CMD, despite the absence of traditional risk factors. Anaemia may be a potential driver of microvascular dysfunction in this population and requires further investigation.
Collapse
Affiliation(s)
- Ashwin Radhakrishnan
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom. .,Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom.
| | - Luke C Pickup
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Anna M Price
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan P Law
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Kirsty C McGee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Larissa Fabritz
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Roxy Senior
- Cardiac Research Unit, Northwick Park Hospital, London, United Kingdom.,Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| |
Collapse
|
28
|
Gaudieri V, Mannarino T, Zampella E, Assante R, D'Antonio A, Nappi C, Cantoni V, Green R, Petretta M, Arumugam P, Cuocolo A, Acampa W. Prognostic value of coronary vascular dysfunction assessed by rubidium-82 PET/CT imaging in patients with resistant hypertension without overt coronary artery disease. Eur J Nucl Med Mol Imaging 2021; 48:3162-3171. [PMID: 33594472 PMCID: PMC8426234 DOI: 10.1007/s00259-021-05239-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/01/2021] [Indexed: 12/24/2022]
Abstract
Purpose The identification of coronary vascular dysfunction may enhance risk stratification in patients with resistant hypertension (RH). We evaluated if impaired coronary vascular function, assessed by rubidium-82 (82Rb) positron emission tomography/computed tomography (PET/CT) imaging, is associated with increased cardiovascular risk in patients with hypertension without overt coronary artery disease (CAD). Methods We studied 517 hypertensive subjects, 26% with RH, without overt CAD, and with normal stress-rest myocardial perfusion imaging at 82Rb PET/CT. The outcome end points were cardiac death, nonfatal myocardial infarction, coronary revascularization, and admission for heart failure. Results Over a median of 38 months (interquartile range 26 to 50), 21 cardiac events (4.1% cumulative event rate) occurred. Patients with RH were older (p < 0.05) and had a higher prevalence of left ventricular hypertrophy (p < 0.001), a lower hyperemic myocardial blood flow (MBF), and myocardial perfusion reserve (MPR) (both p < 0.001) compared to those without. Conversely, coronary artery calcium content and baseline MBF were not different between patients with and without RH. At univariable Cox regression analysis, age, RH, left ventricular ejection fraction, coronary artery calcium score, and reduced MPR were significant predictors of events. At multivariable analysis, age, RH, and reduced MPR (all p < 0.05) were independent predictors of events. Patients with RH and reduced MPR had the highest risk of events and the major risk acceleration over time. Conclusion The findings suggest that the assessment of coronary vascular function may enhance risk stratification in patients with hypertension.
Collapse
Affiliation(s)
- Valeria Gaudieri
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Adriana D'Antonio
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Valeria Cantoni
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Roberta Green
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | | | - Parthiban Arumugam
- Department of Nuclear Medicine, Central Manchester Foundation Trust, Manchester, UK
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy. .,Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy.
| |
Collapse
|
29
|
Premužić V, Stevanović R, Radić P, Salvetti M, Lovrić-Benčić M, Jelaković A, Miličić D, Capak K, Agabiti-Rosei E, Jelaković B. Chronic kidney disease and cardiovascular mortality in patients with atrial fibrillation: European Society of Hypertension project - ESH A Fib. Medicine (Baltimore) 2021; 100:e23975. [PMID: 33466138 PMCID: PMC7808501 DOI: 10.1097/md.0000000000023975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/30/2020] [Indexed: 01/05/2023] Open
Abstract
Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up.Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m2 which was confirmed after 3 months.CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores.Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.
Collapse
Affiliation(s)
- Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | - Petra Radić
- University Hospital Center Sisters of Mercy, Zagreb, Croatia
| | | | - Martina Lovrić-Benčić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
| | - Davor Miličić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | | | - Bojan Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| |
Collapse
|
30
|
Charytan DM, Hsu JY, Mc Causland FR, Waikar SS, Ikizler TA, Raj DS, Landis JR, Mehrotra R, Williams M, DiCarli M, Skali H, Kimmel PL, Kliger AS, Dember LM. Combination Hydralazine and Isosorbide Dinitrate in Dialysis-Dependent ESRD (HIDE): A Randomized, Placebo-Controlled, Pilot Trial. KIDNEY360 2020; 1:1380-1389. [PMID: 35372900 DOI: 10.34067/kid.0004342020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/05/2020] [Indexed: 11/27/2022]
Abstract
Background Combination therapy with isosorbide dinitrate (ISD) and hydralazine (HY) reduces heart failure mortality. The safety and tolerability in individuals requiring maintenance hemodialysis (HD) is unknown. Methods Single-center, randomized, placebo-controlled, double-blind pilot trial to explore safety and tolerability of ISD/HY in maintenance HD. Participants were randomized to placebo or combination ISD/HY. Dose was escalated over 3 weeks from ISD 10 mg/HY 10 mg to ISD 40 mg/HY 75 mg three times per day with the maximum tolerated dose maintained for the subsequent 21 weeks. Primary endpoints included adverse events, adverse events precluding further treatment with study medication, serious hypotension (i.e., requiring hospitalization or emergency room visit), and recurrent intra-dialytic hypotension. Efficacy signals included change in mitral annular E' velocity by tissue Doppler echocardiography and change in left ventricular coronary flow reserve on positron emission tomography. Results A total of 17 individuals were randomized to ISD/HY (N=7) or placebo (N=10). All participants assigned to ISD/HY completed dose escalation to 40/75 mg, but dose reductions were required in two participants. No participants discontinued therapy. There were no serious hypotension events. Recurrent intradialytic hypotension was less frequent with ISD/HY (0.47 events/patient-year) than placebo (1.83 events/patient-year, P=0.04). In contrast, nausea (ISD/HY, 1.90 events/patient-year; placebo, 0.50 events/patient-year, P=0.03) was significantly more frequent, and headache and diarrhea were numerically but not significantly more frequent with ISD/HY. Adverse events were more frequent with ISD/HY (11.4 events/patient-year) than placebo (6.31 events/patient-year). We did not detect between-group differences in the change in E' (P=0.34); ISD/HY showed a mean increase of 0.6 cm/s (SD 1.1), and placebo showed a mean decrease of 0.04 cm/s (SD 0.9). Changes in coronary flow reserve were minimal, -0.3 (0.2) with ISD/HY and -0.03 (0.5) in the placebo group, P=0.19. Conclusions ISD/HY appears to be well tolerated in patients being treated with maintenance HD, but headache and gastrointestinal side effects occur more frequently with ISD/HY compared with placebo.
Collapse
Affiliation(s)
- David M Charytan
- Division of Nephrology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Sushrut S Waikar
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - T Alp Ikizler
- Division of Nephrology and Hypertension, Department of Medicine, and Vanderbilt Center for Kidney Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University School of Medicine, Washington, DC
| | - J Richard Landis
- Department of Biostatistics, Epidemiology and Informatics, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Mark Williams
- Renal Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Marcelo DiCarli
- Departments of Radiology and Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hicham Skali
- Cardiovascular Division, Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Alan S Kliger
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
31
|
Selenium and Coenzyme Q10 Supplementation Improves Renal Function in Elderly Deficient in Selenium: Observational Results and Results from a Subgroup Analysis of a Prospective Randomised Double-Blind Placebo-Controlled Trial. Nutrients 2020; 12:nu12123780. [PMID: 33317156 PMCID: PMC7764721 DOI: 10.3390/nu12123780] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/01/2020] [Accepted: 12/06/2020] [Indexed: 12/20/2022] Open
Abstract
A low selenium intake is found in European countries, and is associated with increased cardiovascular mortality. There is an association between selenium level and the severity of kidney disease. An association between inflammation and selenium intake is also reported. The coenzyme Q10 level is decreased in kidney disease. The aim of this study was to examine a possible association between selenium and renal function in an elderly population low in selenium and coenzyme Q10, and the impact of intervention with selenium and coenzyme Q10 on the renal function. The association between selenium status and creatinine was studied in 589 elderly persons. In 215 of these (mean age 71 years) a randomised double-blind placebo-controlled prospective trial with selenium yeast (200 µg/day) and coenzyme Q10 (200 mg/day) (n = 117) or placebo (n = 98) was conducted. Renal function was determined using measures of glomerular function at the start and after 48 months. The follow-up time was 5.1 years. All individuals were low on selenium (mean 67 μg/L (SD 16.8)). The changes in renal function were evaluated by measurement of creatinine, cystatin-C, and the use of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) algorithm, and by the use of T-tests, repeated measures of variance and ANCOVA analyses. An association between low selenium status and impaired renal function was observed. Intervention causes a significantly lower serum creatinine, and cystatin-C concentration in the active treatment group compared with those on placebo (p = 0.0002 and p = 0.001 resp.). The evaluation with CKD-EPI based on both creatinine and cystatin-C showed a corresponding significant difference (p < 0.0001). All validations showed corresponding significant differences. In individuals with a deficiency of selenium and coenzyme Q10, low selenium status is related to impaired renal function, and thus supplementation with selenium and coenzyme Q10 results in significantly improved renal function as seen from creatinine and cystatin-C and through the CKD-EPI algorithm. The explanation could be related to positive effects on inflammation and oxidative stress as a result of the supplementation.
Collapse
|
32
|
EANM procedural guidelines for PET/CT quantitative myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2020; 48:1040-1069. [PMID: 33135093 PMCID: PMC7603916 DOI: 10.1007/s00259-020-05046-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/17/2020] [Indexed: 12/19/2022]
Abstract
The use of cardiac PET, and in particular of quantitative myocardial perfusion PET, has been growing during the last years, because scanners are becoming widely available and because several studies have convincingly demonstrated the advantages of this imaging approach. Therefore, there is a need of determining the procedural modalities for performing high-quality studies and obtaining from this demanding technique the most in terms of both measurement reliability and clinical data. Although the field is rapidly evolving, with progresses in hardware and software, and the near perspective of new tracers, the EANM Cardiovascular Committee found it reasonable and useful to expose in an updated text the state of the art of quantitative myocardial perfusion PET, in order to establish an effective use of this modality and to help implementing it on a wider basis. Together with the many steps necessary for the correct execution of quantitative measurements, the importance of a multiparametric approach and of a comprehensive and clinically useful report have been stressed.
Collapse
|
33
|
Microvascular disease in chronic kidney disease: the base of the iceberg in cardiovascular comorbidity. Clin Sci (Lond) 2020; 134:1333-1356. [PMID: 32542397 PMCID: PMC7298155 DOI: 10.1042/cs20200279] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) is a relentlessly progressive disease with a very high mortality mainly due to cardiovascular complications. Endothelial dysfunction is well documented in CKD and permanent loss of endothelial homeostasis leads to progressive organ damage. Most of the vast endothelial surface area is part of the microcirculation, but most research in CKD-related cardiovascular disease (CVD) has been devoted to macrovascular complications. We have reviewed all publications evaluating structure and function of the microcirculation in humans with CKD and animals with experimental CKD. Microvascular rarefaction, defined as a loss of perfused microvessels resulting in a significant decrease in microvascular density, is a quintessential finding in these studies. The median microvascular density was reduced by 29% in skeletal muscle and 24% in the heart in animal models of CKD and by 32% in human biopsy, autopsy and imaging studies. CKD induces rarefaction due to the loss of coherent vessel systems distal to the level of smaller arterioles, generating a typical heterogeneous pattern with avascular patches, resulting in a dysfunctional endothelium with diminished perfusion, shunting and tissue hypoxia. Endothelial cell apoptosis, hypertension, multiple metabolic, endocrine and immune disturbances of the uremic milieu and specifically, a dysregulated angiogenesis, all contribute to the multifactorial pathogenesis. By setting the stage for the development of tissue fibrosis and end organ failure, microvascular rarefaction is a principal pathogenic factor in the development of severe organ dysfunction in CKD patients, especially CVD, cerebrovascular dysfunction, muscular atrophy, cachexia, and progression of kidney disease. Treatment strategies for microvascular disease are urgently needed.
Collapse
|
34
|
Prescott E, Pernow J, Saraste A, Åkerblom A, Angerås O, Erlinge D, Grove EL, Hedman M, Jensen LO, Svedlund S, Kjaer M, Lagerström-Fermér M, Gan LM. Design and rationale of FLAVOUR: A phase IIa efficacy study of the 5-lipoxygenase activating protein antagonist AZD5718 in patients with recent myocardial infarction. Contemp Clin Trials Commun 2020; 19:100629. [PMID: 32875138 PMCID: PMC7451793 DOI: 10.1016/j.conctc.2020.100629] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/14/2020] [Accepted: 07/26/2020] [Indexed: 11/07/2022] Open
Abstract
Patients with coronary artery disease remain at increased risk of recurrent life-threatening cardiovascular events even after adequate guideline-based treatment of conventional risk factors, including blood lipid levels. Inflammation is a critical pathway in the pathogenesis of atherosclerosis and is independently associated with risk of recurrent cardiovascular events. Leukotrienes are potent pro-inflammatory and vasoactive mediators synthesized by leukocytes in atherosclerotic lesions. AZD5718 is a novel antagonist of 5-lipoxygenase activating protein that suppresses leukotriene biosynthesis. FLAVOUR is a phase IIa efficacy and safety study of AZD5718 in patients with myocardial infarction 1-4 weeks before randomization. Stenosis of the left anterior descending coronary artery after percutaneous intervention must be <50%, and Thrombolysis In Myocardial Infarction flow grade must be ≥ 2. Enrolled participants receive standard care plus oral AZD5718 200 mg, 50 mg, or placebo once daily for up to 12 weeks (extended from 4 weeks by protocol amendment). The planned sample size is 100 participants randomized to 12 weeks' treatment. Change in urine leukotriene E4 levels is the primary efficacy outcome. FLAVOUR also aims to evaluate whether AZD5718 can improve coronary microvascular function, as measured by transthoracic colour Doppler-assisted coronary flow velocity reserve. Centrally pretrained study sonographers use standardized protocols and equipment. Additional outcomes include assessment of comprehensive echocardiographic parameters (including coronary flow, global strain, early diastolic strain rate and left ventricular ejection fraction), arterial stiffness, biomarkers, health-related quality of life, and safety. Specific anti-inflammatory therapies may represent novel promising treatments to reduce residual risk in patients with coronary artery disease. By combining primary pharmacodynamic and secondary cardiovascular surrogate efficacy outcomes, FLAVOUR aims to investigate the mechanistic basis and potential benefits of AZD5718 treatment in patients with coronary artery disease.
Collapse
Affiliation(s)
- Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Pernow
- Division of Cardiology, Department of Medicine, Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Antti Saraste
- University of Turku and Heart Centre, Turku University Hospital, Turku, Finland
| | - Axel Åkerblom
- Department of Medical Sciences – Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Oskar Angerås
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Erlinge
- Cardiology, Department of Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Erik L. Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Marja Hedman
- Department of Cardiothoracic Surgery, Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Lisette O. Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Sara Svedlund
- Department of Clinical Physiology, Sahlgrenska University Hospital, and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Kjaer
- Early Biometrics and Statistical Innovation, Data Science & AI, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Maria Lagerström-Fermér
- Research and Early Development, Cardiovascular, Renal and Metabolic, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Li-Ming Gan
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Research and Early Development, Cardiovascular, Renal and Metabolic, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| |
Collapse
|
35
|
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. Studies investigating the disproportionate burden of cardiovascular disease have occurred predominantly in the peripheral vasculature, often used noninvasive imaging modalities, and infrequently recruited patients receiving dialysis. This study sought to evaluate invasive coronary dynamic vascular function in patients with end-stage renal failure (ESRF). PATIENTS AND METHODS Patients referred for invasive coronary angiography prior to renal transplantation were invited to participate. Control patients were recruited in parallel. Baseline characteristics were obtained. Coronary diameter (via quantitative coronary angiography) and coronary blood flow (via Doppler Flowire) were measured; macrovascular endothelial-dependent and independent effects were evaluated in response to intracoronary acetylcholine infusion (10 and 10 mol/l) and intracoronary glyceryl trinitrate, respectively. Microvascular function was evaluated by response to adenosine and expressed as coronary flow velocity reserve. Mean values were compared. RESULTS Thirty patients were evaluated: 15 patients with ESRF (mean age 52.1 ± 9, male 73%) and 15 control patients (mean age 53.3 ± 13, male 60%). Comorbidity profile, aside from ESRF, was well matched. Baseline coronary blood flow was similar between groups (101.6 ± 10.3 vs. 103.4 ± 9.1 ml/min, P = 0.71), as was endothelial-dependent response to acetylcholine (159.1 ± 16.9 vs. 171.1 ± 16.8 ml/min, P = 0.41). Endothelial-independent response to glyceryl trinitrate was no different between groups (14.3 ± 3.1 vs. 13.1 ± 2.3%, P = 0.73. A significantly reduced coronary flow velocity reserve was observed in the ESRF cohort compared to controls (2.34 ± 0.4 vs. 3.05 ± 0.3, P = 0.003). CONCLUSION Patients with ESRF had preserved endothelial-dependent function however compared to controls, demonstrated significantly attenuated microvascular reserve. An impaired response to adenosine may not only represent a component of the pathophysiological milieu in patients with ESRF but may also provide a basis for the suboptimal diagnostic performance of vasodilatory stress in this population.
Collapse
|
36
|
Dilsizian V, Gewirtz H, Marwick TH, Kwong RY, Raggi P, Al-Mallah MH, Herzog CA. Cardiac Imaging for Coronary Heart Disease Risk Stratification in Chronic Kidney Disease. JACC Cardiovasc Imaging 2020; 14:669-682. [PMID: 32828780 DOI: 10.1016/j.jcmg.2020.05.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/22/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD), defined as dysfunction of the glomerular filtration apparatus, is an independent risk factor for the development of coronary artery disease (CAD). Patients with CKD are at a substantially higher risk of cardiovascular mortality compared with the age- and sex-adjusted general population with normal kidney function. The risk of CAD and mortality in patients with CKD is correlated with the degree of renal dysfunction including presence of microalbuminuria. A greater cardiovascular risk, albeit lower than for patients receiving dialysis, persists even after kidney transplantation. Congestive heart failure, commonly caused by CAD, also accounts for a significant portion of the cardiovascular-related events observed in CKD. The optimal strategy for the evaluation of CAD in patients with CKD, particularly before renal transplantation, remains a topic of contention spanning over several decades. Although the evaluation of coexisting cardiac disease in patients with CKD is desirable, severe renal dysfunction limits the use of radiographic and magnetic resonance contrast agents due to concerns regarding contrast-induced nephropathy and nephrogenic systemic sclerosis, respectively. In addition, many patients with CKD have extensive and premature (often medial) calcification disproportionate to the severity of obstructive CAD, thereby limiting the diagnostic value of computed tomography angiography. As such, echocardiography, non-contrast-enhanced magnetic resonance, nuclear myocardial perfusion, and metabolic imaging offer a variety of approaches to assess obstructive CAD and cardiomyopathy of advanced CKD without the need for nephrotoxic contrast agents.
Collapse
Affiliation(s)
- Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
| | - Henry Gewirtz
- Department of Medicine (Cardiology Division), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paolo Raggi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Charles A Herzog
- Department of Medicine (Cardiology Division) and Chronic Disease Research Group, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
37
|
Benz DC, Kaufmann PA, von Felten E, Benetos G, Rampidis G, Messerli M, Giannopoulos AA, Fuchs TA, Gräni C, Gebhard C, Pazhenkottil AP, Flammer AJ, Kaufmann PA, Buechel RR. Prognostic Value of Quantitative Metrics From Positron Emission Tomography in Ischemic Heart Failure. JACC Cardiovasc Imaging 2020; 14:454-464. [PMID: 32771569 DOI: 10.1016/j.jcmg.2020.05.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the prognostic and clinical value of quantitative positron emission tomographic (PET) metrics in patients with ischemic heart failure. BACKGROUND Although myocardial flow reserve (MFR) is a strong predictor of cardiac risk in patients without heart failure, it is unknown whether quantitative PET metrics improve risk stratification in patients with ischemic heart failure. METHODS The study included 254 patients referred for stress and rest myocardial perfusion imaging and viability testing using PET. Major adverse cardiac event(s) (MACE) consisted of death, resuscitated sudden cardiac death, heart transplantation, acute coronary syndrome, hospitalization for heart failure, and late revascularization. RESULTS MACE occurred in 170 patients (67%) during a median follow-up of 3.3 years. In a multivariate Cox proportional hazards model including multiple quantitative PET metrics, only MFR predicted MACE significantly (p = 0.013). Beyond age, symptom severity, diabetes mellitus, previous myocardial infarction or revascularization, 3-vessel disease, renal insufficiency, ejection fraction, as well as presence and burden of ischemia, scar, and hibernating myocardium, MFR was strongly associated with MACE (adjusted hazard ratio per increase in MFR by 1: 0.63; 95% confidence interval: 0.45 to 0.91). Incorporation of MFR into a risk assessment model incrementally improved the prediction of MACE (likelihood ratio chi-square test [16] = 48.61 vs. chi-square test [15] = 39.20; p = 0.002). CONCLUSIONS In this retrospective analysis of a single-center cohort, quantitative PET metrics of myocardial blood flow all improved risk stratification in patients with ischemic heart failure. However, in a hypothesis-generating analysis, MFR appears modestly superior to the other metrics as a prognostic index.
Collapse
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Philippe A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Georgios Benetos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Georgios Rampidis
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Andreas J Flammer
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
38
|
Sarnak MJ, Amann K, Bangalore S, Cavalcante JL, Charytan DM, Craig JC, Gill JS, Hlatky MA, Jardine AG, Landmesser U, Newby LK, Herzog CA, Cheung M, Wheeler DC, Winkelmayer WC, Marwick TH. Chronic Kidney Disease and Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:1823-1838. [PMID: 31582143 DOI: 10.1016/j.jacc.2019.08.1017] [Citation(s) in RCA: 363] [Impact Index Per Article: 90.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/26/2019] [Accepted: 08/16/2019] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) is a major risk factor for coronary artery disease (CAD). As well as their high prevalence of traditional CAD risk factors, such as diabetes and hypertension, persons with CKD are also exposed to other nontraditional, uremia-related cardiovascular disease risk factors, including inflammation, oxidative stress, and abnormal calcium-phosphorus metabolism. CKD and end-stage kidney disease not only increase the risk of CAD, but they also modify its clinical presentation and cardinal symptoms. Management of CAD is complicated in CKD patients, due to their likelihood of comorbid conditions and potential for side effects during interventions. This summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference on CAD and CKD (including end-stage kidney disease and transplant recipients) seeks to improve understanding of the epidemiology, pathophysiology, diagnosis, and treatment of CAD in CKD and to identify knowledge gaps, areas of controversy, and priorities for research.
Collapse
Affiliation(s)
- Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, Erlangen, Germany
| | - Sripal Bangalore
- Division of Cardiology, New York University School of Medicine, New York, New York
| | | | - David M Charytan
- Division of Nephrology, New York University School of Medicine, New York, New York
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John S Gill
- Division of Nephrology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes, Brussels, Belgium
| | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
| |
Collapse
|
39
|
Reduced myocardial blood flow reserve in kidney transplant candidates may hamper risk stratification. J Nephrol 2020; 34:197-209. [PMID: 32277424 DOI: 10.1007/s40620-020-00736-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Vasodilator nuclear stress testing is frequently ordered for risk stratification prior to kidney transplantation. Since 82Rb-positron emission tomography-computed tomography can measure myocardial blood flow (MBF), the response to vasodilator stress can be verified rendering the results of the scan more reliable. METHODS We reviewed the MBF response to dipyridamole infusion in 328 patients with end-stage kidney disease (ESKD) prior to transplant (188 hemodialysis-HD, 120 peritoneal dialysis-PD, and 20 pre-dialysis patients-CKD5) and in 100 controls with normal kidney function. A stress/rest MBF ratio ≥ 2 was considered an adequate response to dipyridamole. Coronary artery calcium (CAC) was measured on CT. RESULTS Inadequate MBF response was seen in 36%-HD, 21%-PD, 45%-CKD5 vs. 23%-controls (p = 0.006). Univariable predictors of poor MBF response in ESKD patients were age, diabetes mellitus, and CAC (all p < 0.03) while serum hemoglobin was borderline significant (p = 0.052). Multivariable predictors of a poor MBF response were age (p = 0.002) and lower serum hemoglobin (p = 0.014). Ischemia was identified in 8% of ESKD patients and 24% of controls (p < 0.001). CONCLUSIONS ESKD patients are less likely to respond appropriately to vasodilator stress compared to patients with normal renal function and had a lower incidence of ischemia despite a high pre-test probability of disease. Physicians performing vasodilator stress without MBF measurement should be aware of the high probability of a false negative response.
Collapse
|
40
|
Pelletier-Galarneau M, Dilsizian V. Microvascular Angina Diagnosed by Absolute PET Myocardial Blood Flow Quantification. Curr Cardiol Rep 2020; 22:9. [DOI: 10.1007/s11886-020-1261-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
41
|
Bajaj NS, Singh A, Zhou W, Gupta A, Fujikura K, Byrne C, Harms HJ, Osborne MT, Bravo P, Andrikopolou E, Divakaran S, Bibbo CF, Hainer J, Skali H, Taqueti V, Steigner M, Dorbala S, Charytan DM, Prabhu SD, Blankstein R, Deo RC, Solomon SD, Di Carli MF. Coronary Microvascular Dysfunction, Left Ventricular Remodeling, and Clinical Outcomes in Patients With Chronic Kidney Impairment. Circulation 2019; 141:21-33. [PMID: 31779467 DOI: 10.1161/circulationaha.119.043916] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cardiac dysfunction and cardiovascular events are prevalent among patients with chronic kidney disease without overt obstructive coronary artery disease, but the mechanisms remain poorly understood. Coronary microvascular dysfunction has been proposed as a link between abnormal renal function and impairment of cardiac function and cardiovascular events. We aimed to investigate the relations between chronic kidney disease, coronary microvascular dysfunction, cardiac dysfunction, and adverse cardiovascular outcomes. METHODS Patients undergoing cardiac stress positron emission tomography, echocardiogram, and renal function ascertainment at Brigham and Women's Hospital were studied longitudinally. Patients free of overt coronary (summed stress score <3 and without a history of ischemic heart disease), valvular, and end-organ disease were followed up for the adverse composite outcome of death or hospitalization for myocardial infarction or heart failure. Coronary flow reserve (CFR) was determined from positron emission tomography. Echocardiograms were used to measure cardiac mechanics: diastolic (lateral and septal E/e') and systolic (global longitudinal, radial, and circumferential strain). Image analyses and event adjudication were blinded. The associations between estimated glomerular filtration rate (eGFR), CFR, diastolic and systolic indices, and adverse cardiovascular outcomes were assessed in adjusted models and mediation analyses. RESULTS Of the 352 patients (median age, 65 years; 63% female; 22% black) studied, 35% had an eGFR <60 mL·min-1·1.73 m-2, a median left ventricular ejection fraction of 62%, and a median CFR of 1.8. eGFR and CFR were associated with diastolic and systolic indices, as well as future cardiovascular events (all P<0.05). In multivariable models, CFR, but not eGFR, was independently associated with cardiac mechanics and cardiovascular events. The associations between eGFR, cardiac mechanics, and cardiovascular events were partly mediated via CFR. CONCLUSIONS Coronary microvascular dysfunction, but not eGFR, was independently associated with abnormal cardiac mechanics and an increased risk of cardiovascular events. Coronary microvascular dysfunction may mediate the effect of chronic kidney disease on abnormal cardiac function and cardiovascular events in those without overt coronary artery disease.
Collapse
Affiliation(s)
- Navkaranbir S Bajaj
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.).,Division of Cardiovascular Disease, Department of Internal Medicine, and Department of Radiology, University of Alabama at Birmingham (N.S.B., S.D.P.)
| | - Amitoj Singh
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Ankur Gupta
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Kana Fujikura
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Christina Byrne
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Hendrik J Harms
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Michael T Osborne
- Cardiac MR/PET/CT Program, Department of Radiology, Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.T.O.)
| | - Paco Bravo
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Efstathia Andrikopolou
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Viviany Taqueti
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Michael Steigner
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - David M Charytan
- Nephrology Division, New York University School of Medicine, New York (D.M.C.)
| | - Sumanth D Prabhu
- Division of Cardiovascular Disease, Department of Internal Medicine, and Department of Radiology, University of Alabama at Birmingham (N.S.B., S.D.P.)
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Rahul C Deo
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Scott D Solomon
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Radiology and Medicine; Division of Nuclear Medicine and Molecular Imaging, Department of Radiology; and Divisions of Cardiovascular Medicine and Nephrology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (N.S.B., A.S., W.Z., A.G., K.F., C.B., H.J.H., P.B., E.A., S.D., C.F.B., J.H., H.S., V.T., M.S., S.D., R.B., R.C.D., S.D.S., M.F.D.C.)
| |
Collapse
|
42
|
Cho SG, Kim J, Song HC. Debates over NICE Guideline Update: What Are the Roles of Nuclear Cardiology in the Initial Evaluation of Stable Chest Pain? Nucl Med Mol Imaging 2019; 53:301-312. [PMID: 31723359 PMCID: PMC6821897 DOI: 10.1007/s13139-019-00607-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/12/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022] Open
Abstract
Recent clinical trials have demonstrated the values of cardiac computed tomography (CT) in the initial evaluation of stable chest pain which led to drastic changes in the National Institute for Health and Care Excellence (NICE) guidelines in 2016. According to the updated NICE guidelines, cardiac CT should be performed as the initial cardiac testing in stable chest pain regardless of pre-test probability (PTP) of coronary artery disease (CAD). As a result, cardiac CT is now considered as a validated gatekeeper for assessing stable chest pain, which precedes all the functional studies including nuclear myocardial perfusion imaging (MPI). Nuclear MPI, in contrast, has been assigned as one of the second-line studies, which is inevitably dependent on the results of cardiac CT. However, nuclear MPI has genuine values in the diagnosis, treatment decision, and prognostic stratification of stable chest pain, which cannot be replaced by cardiac CT. In this review, the updated NICE guidelines and related cardiac CT trials will be critically reviewed from the view of nuclear physicians and the exceptional values of nuclear MPI will be described along with the future perspectives.
Collapse
Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| | - Ho-Chun Song
- Department of Nuclear Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 South Korea
| |
Collapse
|
43
|
van de Wouw J, Broekhuizen M, Sorop O, Joles JA, Verhaar MC, Duncker DJ, Danser AHJ, Merkus D. Chronic Kidney Disease as a Risk Factor for Heart Failure With Preserved Ejection Fraction: A Focus on Microcirculatory Factors and Therapeutic Targets. Front Physiol 2019; 10:1108. [PMID: 31551803 PMCID: PMC6737277 DOI: 10.3389/fphys.2019.01108] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 08/12/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) and chronic kidney disease (CKD) co-exist, and it is estimated that about 50% of HF patients suffer from CKD. Although studies have been performed on the association between CKD and HF with reduced ejection fraction (HFrEF), less is known about the link between CKD and heart failure with preserved ejection fraction (HFpEF). Approximately, 50% of all patients with HF suffer from HFpEF, and this percentage is projected to rise in the coming years. Therapies for HFrEF are long established and considered quite successful. In contrast, clinical trials for treatment of HFpEF have all shown negative or disputable results. This is likely due to the multifactorial character and the lack of pathophysiological knowledge of HFpEF. The typical co-existence of HFpEF and CKD is partially due to common underlying comorbidities, such as hypertension, dyslipidemia and diabetes. Macrovascular changes accompanying CKD, such as hypertension and arterial stiffening, have been described to contribute to HFpEF development. Furthermore, several renal factors have a direct impact on the heart and/or coronary microvasculature and may underlie the association between CKD and HFpEF. These factors include: (1) activation of the renin-angiotensin-aldosterone system, (2) anemia, (3) hypercalcemia, hyperphosphatemia and increased levels of FGF-23, and (4) uremic toxins. This review critically discusses the above factors, focusing on their potential contribution to coronary dysfunction, left ventricular stiffening, and delayed left ventricular relaxation. We further summarize the directions of novel treatment options for HFpEF based on the contribution of these renal drivers.
Collapse
Affiliation(s)
- Jens van de Wouw
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Michelle Broekhuizen
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Oana Sorop
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
44
|
Benz DC, von Dahlen AP, Huang W, Messerli M, von Felten E, Benetos G, Giannopoulos AA, Fuchs TA, Gräni C, Gebhard C, Pazhenkottil AP, Gaemperli O, Kaufmann PA, Buechel RR. No differences in rest myocardial blood flow in stunned and hibernating myocardium: insights into the pathophysiology of ischemic cardiomyopathy. Eur J Nucl Med Mol Imaging 2019; 46:2322-2328. [DOI: 10.1007/s00259-019-04440-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/11/2019] [Indexed: 11/27/2022]
|
45
|
Radhakrishnan A, Pickup LC, Price AM, Law JP, Edwards NC, Steeds RP, Ferro CJ, Townend JN. Coronary microvascular dysfunction: a key step in the development of uraemic cardiomyopathy? Heart 2019; 105:1302-1309. [PMID: 31239278 PMCID: PMC6711343 DOI: 10.1136/heartjnl-2019-315138] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/05/2019] [Accepted: 06/02/2019] [Indexed: 01/13/2023] Open
Abstract
The syndrome of uraemic cardiomyopathy, characterised by left ventricular hypertrophy, diffuse fibrosis and systolic and diastolic dysfunction, is common in chronic kidney disease and is associated with an increased risk of cardiovascular morbidity and mortality. The pathophysiological mechanisms leading to uraemic cardiomyopathy are not fully understood. We suggest that coronary microvascular dysfunction may be a key mediator in the development of uraemic cardiomyopathy, a phenomenon that is prevalent in other myocardial diseases that share phenotypical similarities with uraemic cardiomyopathy such as hypertrophic cardiomyopathy and heart failure with preserved ejection fraction. Here, we review the current understanding of uraemic cardiomyopathy, highlight different methods of assessing coronary microvascular function and evaluate the current evidence for coronary microvascular dysfunction in chronic kidney disease.
Collapse
Affiliation(s)
- Ashwin Radhakrishnan
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Luke C Pickup
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Anna M Price
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jonathan P Law
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nicola C Edwards
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| |
Collapse
|
46
|
Pelletier-Galarneau M, Ruddy TD. The potential for PET-guided revascularization of coronary artery disease. Eur J Nucl Med Mol Imaging 2019; 46:1218-1221. [DOI: 10.1007/s00259-019-04316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/21/2019] [Indexed: 10/27/2022]
|
47
|
Abstract
PURPOSE OF REVIEW Radionuclide myocardial perfusion imaging (MPI) continues to be the most reliable modality for diagnosis of hemodynamically significant coronary artery disease (CAD). The application of radionuclide MPI using single photon emission computed tomography (SEPCT) and positron emission tomography (PET) for CAD is reviewed, with emphasis on diagnosis and risk stratification. RECENT FINDINGS Contemporary studies have reported the diagnostic and prognostic value of novel imaging protocols, employing stress-first or stress-only approach. In addition, the superior diagnostic value of PET has been established with a role of assessment of myocardial blood flow to improve risk stratification. The utility of MPI in special populations, such as the elderly, women, and diabetic patients has also been recently evaluated. Furthermore, multicenter studies have reported a similar diagnostic and prognostic value of radionuclide MPI compared with other functional and anatomical techniques for CAD. Radionuclide MPI with SPECT and PET are efficacious for diagnosis and prognosis of CAD. Its universal application in varied patient populations highlights its excellent clinical effectiveness.
Collapse
|
48
|
Schindler TH, Dilsizian V. Coronary Microvascular Dysfunction: Clinical Considerations and Noninvasive Diagnosis. JACC Cardiovasc Imaging 2019; 13:140-155. [PMID: 30982670 DOI: 10.1016/j.jcmg.2018.11.036] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/20/2018] [Accepted: 11/08/2018] [Indexed: 12/18/2022]
Abstract
Chest pain in patients without obstructive coronary artery disease has been realized as a frequent problem encountered in clinical practice. Invasive flow investigations have suggested that up to two-thirds of patients with nonobstructive coronary atherosclerosis may have microvascular dysfunction (MVD). Positron emission tomography myocardial perfusion imaging in conjunction with tracer-kinetic modeling enables the concurrent quantification of myocardial blood flow (MBF) in milliliters per minute per gram of tissue. This allows the assessment of hyperemic MBFs and myocardial flow reserve for the noninvasive identification and characterization of MVD as an important functional substrate for angina symptoms amenable to intensified and individualized medical intervention with nitrates, calcium-channel blockers, statins, angiotensin-converting enzyme inhibitors, and/or angiotensin II type 1 receptor blockers. Recent investigations suggest that cardiac magnetic resonance and computed tomography may also be suitable for the noninvasive detection of MVD. Whether intensified and individualized treatment related improvement or even normalization of hyperemic MBF and/or myocardial flow reserve may lead to a persistent reduction in angina symptoms and/or improved cardiovascular outcome as compared to standard care, deserves further testing in large-scale randomized clinical trials.
Collapse
Affiliation(s)
- Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, Washington University School of Medicine, Saint Louis, Missouri.
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, Maryland
| |
Collapse
|
49
|
Gewirtz H. Coronary circulation: Pressure/flow parameters for assessment of ischemic heart disease. J Nucl Cardiol 2019; 26:459-470. [PMID: 29637523 DOI: 10.1007/s12350-018-1270-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/23/2018] [Indexed: 01/10/2023]
Abstract
Both invasive and non-invasive parameters have been reported for assessment of the physiological status of the coronary circulation. Fractional flow reserve and coronary (or myocardial) flow reserve may be obtained by invasive or non-invasive means. These metrics of coronary stenosis severity have achieved wide clinical acceptance for guiding revascularization decisions and risk stratification. Other indices are obtained invasively (e.g., instantaneous wave-free ratio, iFR; hyperemic stenosis resistance) or non-invasively (e.g., PET absolute myocardial blood flow (mL/min/g)) and have been used for the same purposes. Both iFR, and whole-cycle distal coronary to aortic mean pressure (Pd/Pa) are measured under basal condition and used for assessment of hemodynamic stenosis severity as is index of basal stenosis resistance (BSR). These metrics typically are dichotomized at an empirically derived cut point into "normal" and "abnormal" categories for purposes of clinical decision making and data analysis. Once dichotomized the indices do not always point in the same direction and so confusion may arise. This review, therefore, will present basic principles relevant to understanding commonly employed metrics of the physiological status of the coronary circulation, potential strengths and weaknesses, and hopefully an improved appreciation of the clinical information provided by each.
Collapse
Affiliation(s)
- Henry Gewirtz
- Department of Medicine (Cardiology Division), Harvard Medical School, Massachusetts General Hospital, Boston, MA, 02114, USA.
| |
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update on quantification of myocardial blood flow (MBF) with positron emission tomography (PET) imaging. Technical and clinical aspects of flow quantification with PET are reviewed. RECENT FINDINGS The diagnostic and prognostic values of myocardial flow quantification have been established in numerous studies and in various populations. MBF quantification has also shown itself to be particularly useful in the assessment of coronary microvascular dysfunction and in evaluation of cardiac allograft vasculopathy. Overall, myocardial flow reserve (MFR) and hyperemic MBF can lead to improved risk stratification by providing information complementary to that of other markers of disease severity, such as fractional flow reserve. Flow quantification enhances MPI's ability to detect both significant epicardial disease and microvascular dysfunction. With recent technological and methodological advances, flow quantification with PET is no longer restricted to cyclotron-equipped academic centers.
Collapse
Affiliation(s)
- Matthieu Pelletier-Galarneau
- Gordon Center for Medical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Medical Imaging, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Patrick Martineau
- Gordon Center for Medical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Georges El Fakhri
- Gordon Center for Medical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| |
Collapse
|