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Vikulova DN, Pinheiro-Muller D, Francis G, Halperin F, Sedlak T, Walley K, Fordyce C, Mancini GBJ, Pimstone SN, Brunham LR. Cardiovascular risk and subclinical atherosclerosis in first-degree relatives of patients with premature cardiovascular disease. Am J Prev Cardiol 2024; 19:100704. [PMID: 39076574 PMCID: PMC11284940 DOI: 10.1016/j.ajpc.2024.100704] [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: 04/03/2024] [Revised: 05/30/2024] [Accepted: 06/23/2024] [Indexed: 07/31/2024] Open
Abstract
Background Screening first-degree relatives (FDRs) of patients with premature coronary artery disease (CAD) is recommended but not routinely performed. Objectives To assess the diagnostic yield and impact on clinical management of a clinical and imaging-based screening program of FDRs delivered in the setting of routine clinical care. Methods We recruited FDRs of patients with premature CAD with no personal history of CAD and prospectively assessed for: 1) cardiovascular risk and presence of significant subclinical atherosclerosis (SA) defined as plaque on carotid ultrasound, stenosis >50% or extensive atherosclerosis on coronary computed tomography angiography, or coronary artery calcium scores >100 Agatston units or >75% percentile for age and sex; 2) utilization of preventive medications and lipid levels prior enrolment and after completion of the assessment. Results We assessed 132 FDRs (60.6% females), mean (SD) age 47(17) years old. Cardiovascular risk was high in 38.2%, moderate in 12.2%, and low in 49.6% of FDRs. SA was present in 34.1% of FDRs, including 12.5% in low, 51.9% in moderate, and 55.0% in high calculated risk groups. After assessment, LLT was initiated in 32.6% of FDRs and intensified in 16.0% leading to mean (SD) LDL-C decrease of 1.07(1.10) mmol/L in patients with high calculated risk or SA. LLT was recommended to all patients with high calculated risk, but those with SA were more likely to receive the medications from pharmacies (93.3% vs 60.0%, p = 0.006). Conclusion Screening the FDRs of patients with premature CAD is feasible, may have high diagnostic yield and impact risk factor management.
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Affiliation(s)
- Diana N. Vikulova
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Gordon Francis
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Frank Halperin
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Tara Sedlak
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Keith Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | - GB John Mancini
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Simon N. Pimstone
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Liam R. Brunham
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada
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2
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Maaniitty T, Mäenpää M, Harjulahti E, Kujala I, Stenström I, Nammas W, Knuuti J, Saraste A. Lipid-Lowering Medication and Outcomes After Anatomical and Functional Imaging in Suspected Coronary Artery Disease. JACC Cardiovasc Imaging 2024:S1936-878X(24)00299-7. [PMID: 39207334 DOI: 10.1016/j.jcmg.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 06/13/2024] [Accepted: 07/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Anatomical and functional imaging identify different phenotypes of coronary artery disease (CAD) that may have implications for lipid-lowering medication (LLM). OBJECTIVES The aim of this study was to assess the associations between LLM and long-term outcomes after combined anatomical and functional imaging in patients with suspected obstructive CAD. METHODS Consecutive patients (n = 1,973; 41% men; median age: 63 years) underwent coronary computed tomography angiography (CTA) because of suspected CAD. Patients in whom obstructive CAD was not ruled out by CTA underwent ischemia testing by positron emission tomography. Data on LLM purchases were collected until 2 years, and the combined endpoints of death, myocardial infarction, and unstable angina pectoris were assessed at a median of 6.7 years. RESULTS After imaging, LLM was used by 24% of patients with no CAD, 51% of patients with nonobstructive CAD, 72% of patients with obstructive CAD on CTA without myocardial ischemia, and 91% of patients with myocardial ischemia. The use of LLM decreased during follow-up, with 77% of patients with myocardial ischemia using LLM for 2 years. The use of LLM was associated with a lower annual rate of adverse events in patients with myocardial ischemia (6.1% vs 2.8%; P = 0.032) or obstructive CAD without myocardial ischemia (2.9% vs 1.4%; P = 0.004) but not in patients with nonobstructive CAD (1.5% vs 1.4%; P = 0.89) or no CAD (0.3% vs 0.3%; P = 0.68). CONCLUSIONS The CAD phenotype defined by anatomical and functional imaging guides the use of LLM. The presence of myocardial ischemia and anatomical obstructive coronary lesions were associated with a long-term outcome benefit from LLM.
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Affiliation(s)
- Teemu Maaniitty
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Department of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, Turku, Finland.
| | - Matias Mäenpää
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Esa Harjulahti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Iida Kujala
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Iida Stenström
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Wail Nammas
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Department of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, Turku, Finland
| | - Antti Saraste
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Heart Center, Turku University Hospital and University of Turku, Turku, Finland
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3
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Generoso G, Agarwal V, Shaw LJ, Cardoso R, Blankstein R, Bittencourt MS. Changes in use of preventive medications after assessment of chest pain by coronary computed tomography angiography: A meta-analysis. J Cardiovasc Comput Tomogr 2024; 18:233-242. [PMID: 38262852 DOI: 10.1016/j.jcct.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/11/2023] [Accepted: 01/07/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Coronary computed tomography angiogram (CCTA) is a crucial tool for diagnosing CAD, but its impact on altering preventive medications is not well-documented. This systematic review aimed to compare changes in aspirin and statin therapy following CCTA and functional stress testing in patients with suspected CAD, and in those underwent CCTA when stratified by the presence/absence of plaque. RESULTS Eight studies involving 42,812 CCTA patients and 64,118 cardiac stress testing patients were analyzed. Compared to functional testing, CCTA led to 66 % more changes in statin therapy (pooled RR, 95 % CI [1.28-2.15]) and a 74 % increase in aspirin prescriptions (pooled RR, 95 % CI [1.34-2.26]). For medication modifications based on CCTA results, 13 studies (47,112 patients with statin data) and 11 studies (12,089 patients with aspirin data) were included. Patients with any plaque on CCTA were five times more likely to use or intensify statins compared to those without CAD (pooled RR, 5.40, 95 % CI [4.16-7.00]). Significant heterogeneity remained, which decreased when stratified by diabetes rates. Aspirin use increased eightfold after plaque detection (pooled RR, 8.94 [95 % CI, 4.21-19.01]), especially with obstructive plaque findings (pooled RR, 9.41, 95 % CI [2.80-39.02]). CONCLUSION In conclusion, CCTA resulted in higher changes in statin and aspirin therapy compared to cardiac stress testing. Detection of plaque by CCTA significantly increased statin and aspirin therapy.
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Affiliation(s)
- Giuliano Generoso
- Center for Clinical and Epidemiological Research, University Hospital University of Sao Paulo, Sao Paulo, Brazil
| | - Vikram Agarwal
- Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
| | - Rhanderson Cardoso
- Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Marcio S Bittencourt
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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4
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Palicherla A, Ismayl M, Thandra A, Budoff M, Shaikh K. Evaluation of stable angina by coronary computed tomographic angiography versus standard of care: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 59:67-75. [PMID: 37541837 DOI: 10.1016/j.carrev.2023.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION There is limited data comparing Coronary Computed Tomography Angiography (CCTA) versus the usual Standard of care (SOC) in patients with suspected stable coronary artery disease (CAD). We aimed to perform a systematic review and meta-analysis to compare CCTA versus SOC in patients with stable CAD. METHODS We searched multiple databases for randomized controlled trials (RCTs) comparing CCTA with SOC, which included various functional testing approaches for evaluating stable CAD. We used a random-effects model to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included all-cause mortality, myocardial infarction (MI), hospitalization for unstable angina (UA), invasive angiography, revascularization, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). RESULTS We identified 6 RCTs with 19,881 patients with stable CAD, of which 9995 underwent CCTA, and 9886 underwent SOC. There were no significant differences between CCTA and SOC in terms of all-cause mortality (RR: 0.91; 95 % CI: 0.70-1.19; p = 0.50), MI (RR: 0.78; 95 % CI: 0.58-1.05; p = 0.11), hospitalizations for UA (RR: 1.20; 95 % CI: 0.95-1.51;p = 0.12), invasive angiography (RR: 0.71; 95 % CI: 0.32-1.61; p = 0.42), revascularization (RR:1.25; 95 % CI: 0.83-1.89; p = 0.29), PCI (RR: 1.20; 95 % CI: 0.78-1.85; p = 0.40), and CABG rates (RR: 0.89; 95 % CI: 0.530-1.49; p = 0.65). CONCLUSION In patients with stable CAD, CCTA is associated with similar outcomes compared to the usual Standard of care. Given its potential to quickly rule out severe obstructive disease, its ability to provide non-invasive physiology and identify non-obstructive CAD with plaque information makes it an attractive addition to the available armamentarium to evaluate chest pain.
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Affiliation(s)
- Anirudh Palicherla
- Internal Medicine, Creighton University School of Medicine, Omaha, NE, United States of America.
| | - Mahmoud Ismayl
- Internal Medicine, Creighton University School of Medicine, Omaha, NE, United States of America
| | - Abhishek Thandra
- Interventional Cardiology, Creighton University School of Medicine, Omaha, NE, United States of America.
| | - Matthew Budoff
- David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Kashif Shaikh
- University of Tennessee, Knoxville, United States of America
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5
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Jayadeva PS, Stowers S, Tang EW, Vitola J, Cerci R, Yao J, Westcott J, Elison B, Better N. The impact of coronary calcium score as an addition to myocardial perfusion imaging in altering clinical management (ICCAMPA trial). J Nucl Cardiol 2023; 30:1004-1018. [PMID: 36097241 DOI: 10.1007/s12350-022-03086-2] [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: 01/21/2022] [Accepted: 07/20/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION AIM: Myocardial perfusion imaging (MPI) is a key tool for the identification and risk stratification of patients with coronary artery disease. The use of a coronary calcium score further adds to prognostic data above MPI alone. In this study, our aim was to evaluate the extent to which the use of a coronary artery calcium (CAC) score, when co-reported with MPI, impacts changes in clinical management in patients without a history of coronary artery disease (CAD) undergoing functional imaging. METHODS This is a multicenter international study which incorporated a standardized questionnaire to evaluate changes in clinician management after MPI results were given with and without the additional information of a CAC score. Calcium scoring on a SPECT-CT system was performed via a semiquantitative Shemesh score (0-12) with a 0-3 score from the left main, left anterior descending, left circumflex, and right coronary arteries. CT of the chest was read independently, and non-coronary findings were reported alongside the CAC score. RESULTS A total of 281 patients were enrolled across 3 international centers (Brazil, Australia, New Zealand). Of the 281 patients, 133 (47%) had management altered after the clinician was made aware of the CAC score. The impact of the CAC in changing clinical management was significant, particularly in patients with a negative MPI (P < 0.0001), but also in MPI-positive patients (P = 0.0021). The most common management change was the addition or intensification of statin therapy. CONCLUSION The addition of the CAC component to MPI yielded significant management changes in nearly half of all patients undergoing MPI for suspected CAD. This trend was observed across all centers in the three countries involved and was particularly evident in patient with a negative MPI.
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Affiliation(s)
- Pavithra S Jayadeva
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.
| | - Stephen Stowers
- Department of Cardiology, Palmerston North Hospital, Palmerston North, New Zealand
| | - E W Tang
- Department of Cardiology, Palmerston North Hospital, Palmerston North, New Zealand
| | - Joao Vitola
- Department of Nuclear Medicine, Quanta Diagnostico por Imagem, Curitiba, Brazil
| | - Rodrigo Cerci
- Department of Nuclear Medicine, Quanta Diagnostico por Imagem, Curitiba, Brazil
| | - Jessica Yao
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - James Westcott
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Barry Elison
- Department of Nuclear Medicine, Wollongong Hospital, Wollongong, NSW, Australia
| | - Nathan Better
- Departments of Cardiology and Nuclear Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Departments of Nuclear Medicine and Cardiology, Royal Melbourne Hospital, Parkville, Australia
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6
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Hinton J, Bashar H, Curzen N. Atheroma or ischemia: which is more important for managing patients with stable chest pain? Future Cardiol 2022; 18:417-429. [PMID: 35360934 DOI: 10.2217/fca-2021-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In the evaluation and management of patients with stable chest pain/chronic coronary syndrome, cardiologists need to be able to weigh up the relative merits of managing these patients using either optimal therapy alone or optimal therapy plus revascularization. These decisions rely on an understanding of both the presence and the degree of coronary atheroma and myocardial ischemia, and the impact that these have on patients' symptoms and their prognosis. In this review the authors examine the relative impact of the anatomical and physiological assessment of patients with chronic coronary syndrome and how it can be used to achieve optimal and tailored therapy.
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.,Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
| | - Hussein Bashar
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.,Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
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7
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Slim AM, Fentanes E, Cheezum MK, Parsons IT, Maroules C, Chen B, Abbara S, Branch K, Nagpal P, Shah NR, Thomas DM, Villines TC, Blankstein R, Shaw LJ, Budoff M, Nicol E. The role of cardiovascular CT in occupational health assessment for coronary heart disease: An expert consensus document from the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr 2021; 15:290-303. [PMID: 33926854 DOI: 10.1016/j.jcct.2021.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | | | | | | | | | - Billy Chen
- Cedars-Sinai Medical Center, Baldwin Park, CA, USA
| | - Suhny Abbara
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Prashant Nagpal
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nishant R Shah
- Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Dustin M Thomas
- Parkview Health, Parkview Research Center, Fort Wayne, IN, USA
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Ed Nicol
- Royal Brompton Hospital, London, UK
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8
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Cademartiri F, Casolo G, Clemente A, Seitun S, Mantini C, Bossone E, Saba L, Sverzellati N, Nistri S, Punzo B, Cavaliere C, La Grutta L, Gentile G, Maffei E. Coronary CT angiography: a guide to examination, interpretation, and clinical indications. Expert Rev Cardiovasc Ther 2021; 19:413-425. [PMID: 33884942 DOI: 10.1080/14779072.2021.1915132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The introduction of Cardiac Computed Tomography (CCT) has changed the paradigm in the field of diagnostic cardiovascular medicine. CCT is the primary tool in the assessment of suspected Coronary Artery Disease (CAD) and should be followed by functional assessment when needed to stratify disease and to plan potential interventional or surgical therapy. AREAS COVERED We provided the current state of the knowledge on the main aspects of technique of examination, image interpretation and clinical indications. We have focused our attention on the basic routine applications and activities. EXPERT OPINION The primary role of CCT in suspected CAD will progressively become the standard approach. In general, any situation in which anatomy of the heart and thoracic vessels/structures is mandatory must be approached using CT first, whenever possible. The quantity and quality of information that can be provided by CCT is big and the operators should learn how to deal with this information. On the other hand, CCT is only apparently a straightforward and simple examination. It is actually the most complex diagnostic procedure that can be performed on CT and requires highly skilled operators and state-of-art-technology.
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Affiliation(s)
| | - Giancarlo Casolo
- Department of Cardiology, Ospedale Della Versilia, Viareggio, Italy
| | - Alberto Clemente
- Department of Radiology, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Sara Seitun
- Department of Radiology, Ospedale San Martino, Genova, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Eduardo Bossone
- Department of Cardiology, Ospedale Cardarelli, Naples, Italy
| | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | | | | | - Bruna Punzo
- Department of Radiology, SDN IRCCS, Naples, Italy
| | | | | | | | - Erica Maffei
- Department of Radiology, Area Vasta 1, ASUR Marche, Urbino, Italy
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9
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Olesen KKW, Riis AH, Nielsen LH, Steffensen FH, Nørgaard BL, Jensen JM, Poulsen PL, Thim T, Bøtker HE, Sørensen HT, Maeng M. Risk stratification by assessment of coronary artery disease using coronary computed tomography angiography in diabetes and non-diabetes patients: a study from the Western Denmark Cardiac Computed Tomography Registry. Eur Heart J Cardiovasc Imaging 2020; 20:1271-1278. [PMID: 31220229 DOI: 10.1093/ehjci/jez010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/28/2019] [Indexed: 01/18/2023] Open
Abstract
AIMS We examined whether severity of coronary artery disease (CAD) measured by coronary computed tomography angiography can be used to predict rates of myocardial infarction (MI) and death in patients with and without diabetes. METHODS AND RESULTS A cohort study of consecutive patients (n = 48 731) registered in the Western Denmark Cardiac Computed Tomography Registry from 2008 to 2016. Patients were stratified by diabetes status and CAD severity (no, non-obstructive, or obstructive). Endpoints were MI and death. Event rates per 1000 person-years, unadjusted and adjusted incidence rate ratios were computed. Median follow-up was 3.6 years. Among non-diabetes patients, MI event rates per 1000 person-years were 1.4 for no CAD, 4.1 for non-obstructive CAD, and 9.1 for obstructive CAD. Among diabetes patients, the corresponding rates were 2.1 for no CAD, 4.8 for non-obstructive CAD, and 12.6 for obstructive CAD. Non-diabetes and diabetes patients without CAD had similar low rates of MI [adjusted incidence rate ratio 1.40, 95% confidence interval (CI): 0.71-2.78]. Among diabetes patients, the adjusted risk of MI increased with severity of CAD (no CAD: reference; non-obstructive CAD: adjusted incidence rate ratio 1.71, 95% CI: 0.79-3.68; obstructive CAD: adjusted incidence rate ratio 4.42, 95% CI: 2.14-9.17). Diabetes patients had higher death rates than non-diabetes patients, irrespective of CAD severity. CONCLUSION In patients without CAD, diabetes patients have a low risk of MI similar to non-diabetes patients. Further, MI rates increase with CAD severity in both diabetes and non-diabetes patients; with diabetes patients with obstructive CAD having the highest risk of MI.
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Affiliation(s)
- Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Palle Juel Jensens Boulevard 99, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, Aarhus, Denmark
| | - Anders H Riis
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, Aarhus, Denmark
| | - Lene H Nielsen
- Department of Cardiology, Lillebaelt Hospital, Beriderbakken 4, Vejle, Denmark
| | - Flemming H Steffensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, Aarhus, Denmark.,Department of Cardiology, Lillebaelt Hospital, Beriderbakken 4, Vejle, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juel Jensens Boulevard 99, Aarhus, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juel Jensens Boulevard 99, Aarhus, Denmark
| | - Per L Poulsen
- Departments of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Palle Juel Jensens Boulevard 99, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juel Jensens Boulevard 99, Aarhus, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Alle 43-45, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juel Jensens Boulevard 99, Aarhus, Denmark
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10
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Casolo G, Del Meglio J, Tessa C. Epidemiology and pathophysiologic insights of coronary atherosclerosis relevant for contemporary non-invasive imaging. Cardiovasc Diagn Ther 2020; 10:1906-1917. [PMID: 33381434 PMCID: PMC7758762 DOI: 10.21037/cdt-20-157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/17/2020] [Indexed: 12/20/2022]
Abstract
In the past few years significant changes have taken place in the diagnostic and therapeutic approach to patients with coronary artery disease (CAD) and/or ischemic heart disease (IHD). New discoveries about the development and progression of coronary atherosclerosis have changed the clinical landscape. At the same time a marked decrease in cardiovascular (CV) mortality and CAD incidence have been observed in many Countries but particularly in the most industrialized ones. This fall has been also observed in the incidence of stroke, sudden death, myocardial ischemia, myocardial infarction (MI), and prevalence of CAD. As a consequence, an increasing number of patients with chest pain exhibits non-significant stenosis at both invasive and non-invasive coronary angiography and the rate of coronary vessels revascularizations has greatly reduced. Coronary atherosclerosis and its characteristics have shown to be both diagnostic and therapeutic targets beyond obstructive CAD. The decreased prevalence of CAD in the general population has modified the pre-test probability (PTP) of disease. In this landscape the conventional stress imaging tests appear to have limited accuracy making the diagnosis of obstructive CAD very challenging. These diagnostic tests have been introduced and tested in a population with a much higher probability of disease and therefore the contemporary accuracy of these old tests appear much lower than in the past. In addition, in the past few years the relevance of the traditional ischemia guided coronary intervention strategy has been questioned. Given the low CV events granted by an optimal medical therapy in CAD the major attention has been directed on detecting coronary atherosclerosis. The earlier the better. At the same time, a growing number of data from clinical studies have shown a significant prognostic role for non-obstructive CAD and coronary atherosclerosis. All these facts have shifted the clinicians' attention from the functional evaluation of the coronary circulation to the anatomic burden of disease.
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Affiliation(s)
- Giancarlo Casolo
- Cardiology Department, Versilia Hospital, Lido di Camaiore, Italy
| | | | - Carlo Tessa
- Radiology Department, Versilia Hospital, Lido di Camaiore, Italy
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11
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Honigberg MC, Lander BS, Baliyan V, Jones-O'Connor M, Healy EW, Scholtz JE, Nagurney JT, Hoffmann U, Ghoshhajra BB, Natarajan P. Preventive Management of Nonobstructive CAD After Coronary CT Angiography in the Emergency Department. JACC Cardiovasc Imaging 2020; 13:437-448. [PMID: 31326481 PMCID: PMC6954346 DOI: 10.1016/j.jcmg.2019.04.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/26/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This study sought to assess medical management of patients found to have nonobstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) performed in the emergency department (ED). BACKGROUND Contemporary recognition and management of nonobstructive CAD discovered on CCTA performed in the ED is unknown. METHODS Patients undergoing CCTA in the authors' hospital's ED between November 2013 and March 2018 who also received primary care within the authors' health system were studied. All patients with nonobstructive CAD, defined as 1% to 49% maximum luminal stenosis on CCTA, were included, along with a control group without CAD in a 1 case:1 control fashion. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk prior to CCTA was estimated using the Pooled Cohort Equations. Management changes were recorded until 6 months after CCTA. Multivariate logistic regression tested the association between CCTA result and follow-up statin prescription, adjusting for cardiovascular risk factors and baseline statin use. RESULTS The cohort included 510 patients with nonobstructive CAD and 510 controls. Prevalence of statin prescription increased from 38.8% to 56.1% among patients with nonobstructive CAD (p < 0.001) and 18.0% to 20.4% among controls (p = 0.01), representing a 7.1-fold relative difference (95% confidence interval [CI]: 4.4 to 23.0; p < 0.001) in multivariate analysis. However, 30.0% of patients with nonobstructive CAD and ≥20% 10-year ASCVD risk were not prescribed a statin at the end of follow-up. Cardiologist evaluation was independently associated with statin prescription after adjustment for ASCVD risk factors (odds ratio [OR] 4.4; 95% CI: 2.4 to 8.5; p < 0.001). A Coronary Artery Disease Reporting and Data System class 1 to 2 result was associated with lower low-density lipoprotein cholesterol by 12.1 mg/dl at mean 1.9-year follow-up (p < 0.001). CONCLUSIONS Incidental subclinical atherosclerosis on CCTA performed in the ED increases the likelihood of statin prescription, but opportunities to improve allocation of indicated preventive therapies remain.
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Affiliation(s)
- Michael C Honigberg
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Bradley S Lander
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Vinit Baliyan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Maeve Jones-O'Connor
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emma W Healy
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jan-Erik Scholtz
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Harvard Medical School, Boston, Massachusetts; Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Udo Hoffmann
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Pradeep Natarajan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts; Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Hull RA, Berger JM, Boster JM, Williams MU, Sharp AJ, Fentanes E, Maroules CD, Cury RC, Thomas DM. Adoption of coronary artery disease - Reporting and Data System (CAD-RADS™) and observed impact on medical therapy and systolic blood pressure control. J Cardiovasc Comput Tomogr 2020; 14:421-427. [PMID: 32005447 DOI: 10.1016/j.jcct.2020.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/06/2020] [Accepted: 01/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND CAD-RADS was developed to standardize communication of per-patient maximal stenosis on coronary CT angiography (CCTA) and provide treatment recommendations and may impact primary prevention care and resource utilization. The authors sought to evaluate CAD-RADS adoption on preventive medical therapy and risk factor control amongst a mixed provider population. METHODS Statins, aspirin (ASA), systolic blood pressure and, when available, lipid panel changes were abstracted for 1796 total patients undergoing CCTA in the 12 months before (non-standard reporting, NSR, cohort) and after adoption of the CAD-RADS reporting template. Only initiation of a medication in a treatment naïve patient, escalation from baseline dose, or transition to a higher potency was considered an escalation/initiation in lipid therapy. RESULTS The CAD-RADS reporting template was utilized in 83.7% (751/897) of CCTAs after the CAD-RADS adoption period. After adjusting for any coronary artery disease (CAD) on CCTA, statin initiation/escalation was more commonly observed in the CAD-RADS cohort (aOR 1.46; 95%CI 1.12-1.90, p = 0.005), driven by higher rates of new statin initiation (aOR 1.79; 95%CI 1.23-2.58, p = 0.002). This resulted in a higher observed rates of total cholesterol improvement in the CAD-RADS cohort (58% vs 49%, p = 0.016). New ASA initiation was similar between reporting templates after adjustment for CAD on CCTA (aOR 1.40; 95%CI 0.97-2.02, p = 0.069). The ordering provider's specialty (cardiology vs non-cardiology) did not significantly impact the observed differences in initiation/escalation of statins and ASA (pinteraction = NS). CONCLUSIONS Adoption of CAD-RADS reporting was associated with increased utilization of preventive medications, regardless of ordering provider specialty.
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Affiliation(s)
- Robert A Hull
- Department of Medicine, Cardiology Division, Brooke Army Medical Center, San Antonio, TX, USA
| | - Jeremy M Berger
- Department of Flight Medicine, Little Rock Air Force Base, AR, USA
| | - Joshua M Boster
- Department of Medicine, Internal Medicine Residency, Brooke Army Medical Center, San Antonio, TX, USA
| | - Michael U Williams
- Department of Medicine, Division of Cardiology, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Alec J Sharp
- Department of Medicine, Cardiology Division, Brooke Army Medical Center, San Antonio, TX, USA
| | - Emilio Fentanes
- Department of Medicine, Division of Cardiology, Tripler Army Medical Center, Honolulu, HI, USA.
| | | | - Ricardo C Cury
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA.
| | - Dustin M Thomas
- Department of Medicine, Cardiology Division, Brooke Army Medical Center, San Antonio, TX, USA.
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Williams MC, Newby DE, Nicol ED. Coronary atherosclerosis imaging by CT to improve clinical outcomes. J Cardiovasc Comput Tomogr 2019; 13:281-287. [PMID: 30952611 PMCID: PMC6928571 DOI: 10.1016/j.jcct.2019.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/13/2019] [Accepted: 03/25/2019] [Indexed: 01/13/2023]
Abstract
Coronary artery disease remains an important cause of morbidity and mortality world-wide. Coronary Computed Tomography Angiography (CCTA) has excellent diagnostic accuracy and the identification and stratification of coronary artery disease is associated with improved prognosis in multiple studies. Recent randomized controlled trials have shown that in patients with stable coronary artery disease, CCTA is associated with improved diagnosis, changes in investigations, changes in medical treatment and appropriate selection for revascularization. Importantly this diagnostic approach reduces the long-term risk of fatal and non-fatal myocardial infarction. The identification of adverse plaques on CCTA is known to be associated with an increased risk of acute coronary syndrome, but does not appear to be predictive of long-term outcomes independent of coronary artery calcium burden. Future research will involve the assessment of outcomes after CCTA in patients with acute chest pain and asymptomatic patients. In addition, more advanced quantification of plaque subtypes, vascular inflammation and coronary flow dynamics may identify further patients at increased risk.
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Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK; Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK.
| | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK; Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - Edward D Nicol
- Royal Brompton and Harefield NHS Foundation Trust Departments of Cardiology and Radiology, London, UK; National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK
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Cheezum MK, Shah NR. Is a Picture Worth a Thousand Guidelines? JACC Cardiovasc Imaging 2019; 13:449-451. [PMID: 31326489 DOI: 10.1016/j.jcmg.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/06/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Michael K Cheezum
- Department of Cardiology, Parkview Health, Parkview Research Center, Fort Wayne, Indiana.
| | - Nishant R Shah
- Division of Cardiovascular Medicine, Department of Medicine, Lifespan Cardiovascular Institute, Brown University Alpert School of Medicine, Providence, Rhode Island
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Blankstein R, Bittencourt MS, Bhatt DL. Coronary CTA in the Evaluation of Stable Chest Pain: Clear Benefits, But Not for All. J Am Coll Cardiol 2019; 69:1771-1773. [PMID: 28385305 DOI: 10.1016/j.jacc.2017.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Márcio Sommer Bittencourt
- Division of Internal Medicine, University Hospital and State of São Paulo Cancer Institute (ICESP), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center Hospital Israelita Albert Einstein and School of Medicine, Faculdade Israelita de Ciência da Saúde Albert Einstein, São Paulo, Brazil
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
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Taqueti VR, Blankstein R. Understanding Sex Differences in Coronary Artery Disease Risk: Is Coronary Anatomy Sufficient? Circ Cardiovasc Imaging 2019; 10:CIRCIMAGING.117.006766. [PMID: 28790125 DOI: 10.1161/circimaging.117.006766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Viviany R Taqueti
- From the Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine and Division of Nuclear Medicine and Molecular Imaging, Department and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- From the Cardiovascular Imaging Program, Division of Cardiovascular Medicine, Department of Medicine and Division of Nuclear Medicine and Molecular Imaging, Department and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Tzolos E, Newby DE. Coronary Computed Tomography Angiography Improving Outcomes in Patients with Chest Pain. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019; 12:15. [PMID: 33442442 PMCID: PMC7116579 DOI: 10.1007/s12410-019-9492-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Purpose of Review To provide an overview of recent studies of coronary computed tomography angiography (CCTA) and how it has helped to improve clinical outcomes for patients presenting with chest pain. Recent Findings Randomised controlled trials have uniformly demonstrated that the use of CCTA is associated with improvements in patient diagnosis, management and treatments as well as the avoidance of unnecessary invasive coronary angiography. These changes have been associated with consistent reductions in long-term rates of fatal or non-fatal myocardial infarction. Summary Major beneficial effects in clinical management and patient outcomes are seen with the use of coronary computed tomography angiography. CCTA might be considered to be the first test of choice for the investigation of coronary heart disease.
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Affiliation(s)
- Evangelos Tzolos
- British Heart Foundation, Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Edinburgh EH16 4SA, Scotland, UK
| | - David E. Newby
- British Heart Foundation, Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Edinburgh EH16 4SA, Scotland, UK
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18
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Coronary CT Angiography in New-Onset Stable Chest Pain. J Am Coll Cardiol 2019; 73:903-905. [DOI: 10.1016/j.jacc.2018.08.2205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/08/2018] [Accepted: 08/12/2018] [Indexed: 01/06/2023]
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19
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Mols RE, Nørgaard BL, Vedsted P, Farkas DK, Bøtker HE, Jensen JM. General practice preventive health care in non-obstructive coronary artery disease determined by coronary computed tomography angiography. Int J Cardiol 2019; 278:14-21. [DOI: 10.1016/j.ijcard.2018.09.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 08/19/2018] [Accepted: 09/24/2018] [Indexed: 01/24/2023]
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20
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van Rosendael AR, Shaw LJ, Xie JX, Dimitriu-Leen AC, Smit JM, Scholte AJ, van Werkhoven JM, Callister TQ, DeLago A, Berman DS, Hadamitzky M, Hausleiter J, Al-Mallah MH, Budoff MJ, Kaufmann PA, Raff G, Chinnaiyan K, Cademartiri F, Maffei E, Villines TC, Kim YJ, Feuchtner G, Lin FY, Jones EC, Pontone G, Andreini D, Marques H, Rubinshtein R, Achenbach S, Dunning A, Gomez M, Hindoyan N, Gransar H, Leipsic J, Narula J, Min JK, Bax JJ. Superior Risk Stratification With Coronary Computed Tomography Angiography Using a Comprehensive Atherosclerotic Risk Score. JACC Cardiovasc Imaging 2019; 12:1987-1997. [PMID: 30660516 DOI: 10.1016/j.jcmg.2018.10.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/19/2018] [Accepted: 10/19/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study was designed to assess the prognostic value of a new comprehensive coronary computed tomography angiography (CTA) score compared with the stenosis severity component of the Coronary Artery Disease-Reporting and Data System (CAD-RADS). BACKGROUND Current risk assessment with coronary CTA is mainly focused on maximal stenosis severity. Integration of plaque extent, location, and composition in a comprehensive model may improve risk stratification. METHODS A total of 2,134 patients with suspected but without known CAD were included. The predictive value of the comprehensive CTA score (ranging from 0 to 42 and divided into 3 groups: 0 to 5, 6 to 20, and >20) was compared with the CAD-RADS combined into 3 groups (0% to 30%, 30% to 70% and ≥70% stenosis). Its predictive performance was internally and externally validated (using the 5-year follow-up dataset of the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry], n = 1,971). RESULTS The mean age of patients was 55 ± 13 years, mean follow-up 3.6 ± 2.8 years, and 130 events (myocardial infarction or death) occurred. The new, comprehensive CTA score showed strong and independent predictive value using the Cox proportional hazard analysis. A model including clinical variables plus comprehensive CTA score showed better discrimination of events compared with a model consisting of clinical variables plus CAD-RADS (0.768 vs. 0.742, p = 0.001). Also, the comprehensive CTA score correctly reclassified a significant proportion of patients compared with the CAD-RADS (net reclassification improvement 12.4%, p < 0.001). Good predictive accuracy was reproduced in the external validation cohort. CONCLUSIONS The new comprehensive CTA score provides better discrimination and reclassification of events compared with the CAD-RADS score based on stenosis severity only. The score retained similar prognostic accuracy when externally validated. Anatomic risk scores can be improved with the addition of extent, location, and compositional measures of atherosclerotic plaque. (Comprehensive CTA risk score calculator is available at: http://18.224.14.19/calcApp/).
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Affiliation(s)
- Alexander R van Rosendael
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Leslee J Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joe X Xie
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Jeff M Smit
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arthur J Scholte
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | | | - Daniel S Berman
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
| | - Jeorg Hausleiter
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
| | - Mouaz H Al-Mallah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | | | | | | | | | - Erica Maffei
- Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy
| | - Todd C Villines
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda
| | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Fay Y Lin
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Erica C Jones
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Gianluca Pontone
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy
| | - Daniele Andreini
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy
| | - Hugo Marques
- UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal
| | - Ronen Rubinshtein
- Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | | | - Millie Gomez
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Niree Hindoyan
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Heidi Gransar
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California
| | - Jonathon Leipsic
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jagat Narula
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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Weir-McCall J, Bonnici-Mallia M, Ramkumar P, Nath A, Houston J. Whole-body magnetic resonance angiography. Clin Radiol 2019; 74:3-12. [DOI: 10.1016/j.crad.2018.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 04/10/2018] [Accepted: 05/29/2018] [Indexed: 01/01/2023]
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Schulman-Marcus J, Lin FY, Gransar H, Berman D, Callister T, DeLago A, Hadamitzky M, Hausleiter J, Al-Mallah M, Budoff M, Kaufmann P, Achenbach S, Raff G, Chinnaiyan K, Cademartiri F, Maffei E, Villines T, Kim YJ, Leipsic J, Feuchtner G, Rubinshtein R, Pontone G, Andreini D, Marques H, Chang HJ, Chow BJW, Cury RC, Dunning A, Shaw L, Min JK. Coronary revascularization vs. medical therapy following coronary-computed tomographic angiography in patients with low-, intermediate- and high-risk coronary artery disease: results from the CONFIRM long-term registry. Eur Heart J Cardiovasc Imaging 2018; 18:841-848. [PMID: 28329294 PMCID: PMC5837582 DOI: 10.1093/ehjci/jew287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/24/2017] [Indexed: 01/10/2023] Open
Abstract
Aims To identify the effect of early revascularization on 5-year survival in patients with CAD diagnosed by coronary-computed tomographic angiography (CCTA). Methods and results We examined 5544 stable patients with suspected CAD undergoing CCTA who were followed a median of 5.5 years in a large international registry. Patients were categorized as having low-, intermediate-, or high-risk CAD based on CCTA findings. Two treatment groups were defined: early revascularization within 90 days of CCTA (n = 1171) and medical therapy (n = 4373). To account for the non-randomized referral to revascularization, we developed a propensity score by logistic regression. This score was incorporated into Cox proportional hazard models to calculate the effect of revascularization on all-cause mortality. Death occurred in 363 (6.6%) patients and was more frequent in medical therapy. In multivariable models, when compared with medical therapy, the mortality benefit of revascularization varied significantly over time and by CAD risk (P for interaction 0.04). In high-risk CAD, revascularization was significantly associated with lower mortality at 1 year (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.11–0.47) and 5 years (HR 0.31, 95% CI 0.18–0.54). For intermediate-risk CAD, revascularization was associated with reduced mortality at 1 year (HR 0.45, 95% CI 0.22–0.93) but not 5 years (HR 0.63, 95% CI 0.33–1.20). For low-risk CAD, there was no survival benefit at either time point. Conclusions Early revascularization was associated with reduced 1-year mortality in intermediate- and high-risk CAD detected by CCTA, but this association only persisted for 5-year mortality in high-risk CAD.
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Affiliation(s)
| | - Fay Y Lin
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
| | - Heidi Gransar
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tracy Callister
- Tennessee Heart and Vascular Institute, Hendersonville, TN, USA
| | | | - Martin Hadamitzky
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Joerg Hausleiter
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Mouaz Al-Mallah
- King Saud Bin Abdul Aziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul Aziz Cardiac Center, Ministry of National Guard, Health Affairs, Saudi Arabia
| | - Matthew Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA
| | | | | | | | - Kavitha Chinnaiyan
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
| | - Filippo Cademartiri
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
| | - Erica Maffei
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
| | - Todd Villines
- Department of Medicine, Walter Reed Medical Center, Washington, DC, USA
| | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronen Rubinshtein
- Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gianluca Pontone
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Daniele Andreini
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Hugo Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Benjamin J W Chow
- Department of Medicine and Radiology, University of Ottawa, ON, Canada
| | | | | | - Leslee Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
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Prognostic value of age adjusted segment involvement score as measured by coronary computed tomography: a potential marker of vascular age. Heart Vessels 2018; 33:1288-1300. [DOI: 10.1007/s00380-018-1188-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 05/18/2018] [Indexed: 10/16/2022]
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Abstract
OPINION STATEMENT Coronary CT angiography (CTA) is a highly accurate test for the diagnosis of coronary artery disease (CAD), with its use guided by numerous contemporary appropriate use criteria and clinical guidelines. Unique among non-invasive tests for CAD, coronary CTA provides direct visualization of coronary atherosclerosis for the assessment of angiographic stenosis, as well as validated measures of plaque vulnerability. Long-term studies now clearly demonstrate that the absence of CAD on coronary CTA identifies a patient that is at very low risk for future cardiovascular events. Conversely, the presence, location, and severity of CAD as measured on coronary CTA provide powerful prognostic information that is superior to traditional risk factors and other clinical variables. Observational studies and data obtained from clinical trials suggest that the anatomic information derived from coronary CTA significantly increases the utilization of statins and aspirin. Furthermore, these changes are associated with reductions in the risk for mortality, revascularizations, and incident myocardial infarctions among subjects with coronary atherosclerosis. As a result, current societal consensus statements have attempted to standardize coronary CTA reporting, to include incorporation of vulnerable plaque features and recommendations on the use of preventive therapies, such as statins, so to more consistently link important prognostic findings on coronary CTA to appropriate preventive and therapeutic interventions. Automated measures of total coronary plaque volume, machine learning, and CT-derived fractional flow reserve may further refine the prognostic accuracy of coronary CTA. Herein, we summarize recently published literature that reports the long-term (≥ 5 years of follow-up) prognostic usefulness of coronary CTA.
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Ladapo JA, Coles A, Dolor RJ, Mark DB, Cooper L, Lee KL, Goldberg J, Shapiro MD, Hoffmann U, Douglas PS. Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America. BMJ Open 2017; 7:e016364. [PMID: 28965093 PMCID: PMC5640109 DOI: 10.1136/bmjopen-2017-016364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To evaluate potential gaps in preventive medical therapy and healthy lifestyle practices among symptomatic patients with suspected coronary artery disease (CAD) seeing primary care physicians and cardiologists and how gaps vary by sociodemographic characteristics and baseline cardiovascular risk. DESIGN Cross-sectional study assessing potential preventive gaps. PARTICIPANTS 10 003 symptomatic outpatients evaluated by primary care physicians, cardiologists or other specialists for suspected CAD. SETTING PROspective Multicenter Imaging Study for Evaluation of Chest Painfrom 2010 to 2014. MEASURES Primary measures were absence of an antihypertensive, statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for renal protection in patients with hypertension, dyslipidaemia or diabetes, respectively, and being sedentary, smoking or being obese. RESULTS Preventive treatment gaps affected 14% of patients with hypertension, 36% of patients with dyslipidaemia and 32% of patients with diabetes. Overall, 49% of patients were sedentary, 18% currently smoked and 48% were obese. Women were significantly more likely to not take a statin for dyslipidaemia and to be sedentary. Patients with lower socioeconomic status were also significantly more likely to not take a statin. Compared with Whites, Blacks were significantly more likely to be obese, while Asians were less likely to smoke or be obese. High-risk patients sometimes experienced larger preventive care gaps than low-risk patients. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event (HR 1.35, 95% CI 1.02 to 1.82). CONCLUSIONS Among contemporary, symptomatic patients with suspected CAD, significant gaps exist in preventive care and lifestyle practices, and high-risk patients sometimes had larger gaps. Differences by sex, age, race/ethnicity, socioeconomic status and geography are modest but contribute to disparities and have implications for improving opulation health. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event. CLINICAL TRIAL REGISTRATION Clinical Trials.gov identifier NCT01174550.
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Affiliation(s)
- Joseph A Ladapo
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Adrian Coles
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rowena J Dolor
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel B Mark
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lawton Cooper
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Kerry L Lee
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela S Douglas
- Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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Hwang IC, Choi SJ, Choi JE, Ko EB, Suh JK, Choi I, Kang HJ, Kim YJ, Kim JY. Comparison of mid- to long-term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta-analysis of randomized trials. Clin Cardiol 2017; 40:1129-1138. [PMID: 28914973 DOI: 10.1002/clc.22799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/07/2017] [Accepted: 08/14/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD). HYPOTHESIS CCTA as initial diagnostic strategy results in better mid- to long-term outcomes than usual care in patients with suspected CAD. METHODS We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow-up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all-cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies. RESULTS Twelve trials were included (20 014 patients; mean follow-up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52-0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all-cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12-2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11-2.00, P = 0.007). CONCLUSIONS Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.
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Affiliation(s)
- In-Chang Hwang
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sol Ji Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Ji Eun Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Eun-Bi Ko
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea.,Department of Health Administration, Yonsei University Graduate School, Wonju, Republic of Korea
| | - Jae Kyung Suh
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Insun Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - Hyun-Jae Kang
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong-Jin Kim
- Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joo Youn Kim
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Republic of Korea
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Gupta A, Lau E, Varshney R, Hulten EA, Cheezum M, Bittencourt MS, Blaha MJ, Wong ND, Blumenthal RS, Budoff MJ, Umscheid CA, Nasir K, Blankstein R. The Identification of Calcified Coronary Plaque Is Associated With Initiation and Continuation of Pharmacological and Lifestyle Preventive Therapies: A Systematic Review and Meta-Analysis. JACC Cardiovasc Imaging 2017; 10:833-842. [PMID: 28797402 PMCID: PMC5761651 DOI: 10.1016/j.jcmg.2017.01.030] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/15/2017] [Accepted: 01/19/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to assess the odds of initiation or continuation of pharmacological and lifestyle preventive therapies in patients with nonzero versus zero coronary artery calcium (CAC) score detected on cardiac computed tomography. BACKGROUND Detection of calcified coronary plaque could serve as a motivational tool for physicians and patients to intensify preventive therapies. METHODS We searched PubMed, EMBASE (Excerpta Medica database), Web of Science, Cochrane CENTRAL (Cochrane central register of controlled trials), ClinicalTrials.gov, and the International Clinical Trials Registry Platform for studies evaluating the association of CAC scores with downstream pharmacological or lifestyle interventions for prevention of cardiovascular disease. Pooled odds ratios (ORs) of downstream interventions were obtained using the DerSimonian and Laird random effects model. RESULTS After a review of 6,256 citations and 54 full-text papers, 6 studies (11,256 participants, mean follow-up time: 1.6 to 6.0 years) were included. Pooled estimates of the odds of aspirin initiation (OR: 2.6; 95% confidence interval [CI]: 1.8 to 3.8), lipid-lowering medication initiation (OR: 2.9; 95% CI: 1.9 to 4.4), blood pressure-lowering medication initiation (OR: 1.9; 95% CI: 1.6 to 2.3), lipid-lowering medication continuation (OR: 2.3; 95% CI: 1.6 to 3.3), increase in exercise (OR: 1.8; 95% CI: 1.4 to 2.4), and dietary change (OR: 1.9; 95% CI: 1.5 to 2.5) were higher in individuals with nonzero CAC versus zero CAC scores, but not for aspirin or blood pressure-lowering medication continuation. When assessed within individual studies, these findings remained significant after adjustment for baseline patient characteristics and cardiovascular risk factors. CONCLUSIONS This systematic review and meta-analysis suggests that nonzero CAC score, identifying calcified coronary plaque, significantly increases the likelihood of initiation or continuation of pharmacological and lifestyle therapies for the prevention of cardiovascular disease.
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Affiliation(s)
- Ankur Gupta
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Lau
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi Varshney
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward A Hulten
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Walter Reed National Military Medical Center, Washington, DC
| | - Michael Cheezum
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Marcio S Bittencourt
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Clinical and Epidemiological Research, University Hospital, University of Sao Paulo, Sao Paulo, Brazil; Hospital Israelita Albert Einstein and Faculdade Israelita de Ciencias da Saude Albert Einstein, Sao Paulo, Brazil
| | - Michael J Blaha
- John Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Nathan D Wong
- University of California, Irvine, Irvine, California
| | - Roger S Blumenthal
- John Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Matthew J Budoff
- Harbor-University of California at Los Angeles, Torrance, California
| | | | - Khurram Nasir
- John Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Baptist Health South Florida, Miami, Florida
| | - Ron Blankstein
- Cardiovascular Imaging Program, Division of Cardiovascular Medicine and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Bittencourt MS, Blankstein R. Coronary computed tomography angiography: How should we act on what we find? J Nucl Cardiol 2017; 24:1279-1281. [PMID: 27072002 DOI: 10.1007/s12350-016-0494-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 03/29/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Márcio Sommer Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP), University of São Paulo, São Paulo, Brazil
- Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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Jørgensen ME, Andersson C, Nørgaard BL, Abdulla J, Shreibati JB, Torp-Pedersen C, Gislason GH, Shaw RE, Hlatky MA. Functional Testing or Coronary Computed Tomography Angiography in Patients With Stable Coronary Artery Disease. J Am Coll Cardiol 2017; 69:1761-1770. [PMID: 28385304 DOI: 10.1016/j.jacc.2017.01.046] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 01/23/2017] [Accepted: 01/23/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND The choice of either anatomical or functional noninvasive testing to evaluate suspected coronary artery disease might affect subsequent clinical management and outcomes. OBJECTIVES This study analyzed the association of initial noninvasive cardiac testing in outpatients with stable symptoms, with subsequent use of medications, invasive procedures, and clinical outcomes. METHODS We studied patients enrolled in a Danish nationwide register who underwent initial noninvasive cardiac testing with either coronary computed tomography angiography (CTA) or functional testing (exercise electrocardiography or nuclear stress testing) from 2009 to 2015. Further use of noninvasive testing, invasive procedures, medications, and medical costs within 120 days were evaluated. Risks of long-term mortality and myocardial infarction (MI) were analyzed using adjusted Cox proportional hazard models. RESULTS A total of 86,705 patients underwent either functional testing (n = 53,744, mean age 57.4 years, 49% males) or coronary CTA (n = 32,961, mean age 57.4 years, 45% males), and were followed for a median of 3.6 years. Compared with functional testing, there was significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%); all p < 0.001 after coronary CTA. The mean costs of subsequent testing, invasive procedures, and medications were higher after coronary CTA ($995 vs. $718; p < 0.001). Unadjusted rates of mortality (2.1% vs. 4.0%) and MI hospitalization (0.8% vs. 1.5%) were lower after coronary CTA than functional testing (both p < 0.001). After adjustment, coronary CTA was associated with a comparable all-cause mortality (hazard ratio: 0.96; 95% confidence interval: 0.88 to 1.05), and a lower risk of MI (hazard ratio: 0.71; 95% confidence interval: 0.61 to 0.82). CONCLUSIONS In stable patients undergoing initial evaluation for suspected coronary artery disease, coronary CTA was associated with greater use of statins, aspirin, and invasive procedures, and higher costs than functional testing. Coronary CTA was associated with a lower risk of MI, but a similar risk of all-cause mortality.
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Affiliation(s)
- Mads E Jørgensen
- Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California; The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Charlotte Andersson
- The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Division of Cardiology, Department of Internal Medicine, Glostrup University Hospital, Glostrup, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital-Skejby, Aarhus, Denmark
| | - Jawdat Abdulla
- Division of Cardiology, Department of Internal Medicine, Glostrup University Hospital, Glostrup, Denmark
| | - Jacqueline B Shreibati
- Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Gunnar H Gislason
- The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark
| | - Richard E Shaw
- Department of Medicine, Division of Cardiology, California Pacific Medical Center, San Francisco, California
| | - Mark A Hlatky
- Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Stefanadis C, Antoniou CK, Tsiachris D, Pietri P. Coronary Atherosclerotic Vulnerable Plaque: Current Perspectives. J Am Heart Assoc 2017; 6:JAHA.117.005543. [PMID: 28314799 PMCID: PMC5524044 DOI: 10.1161/jaha.117.005543] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | | | - Dimitrios Tsiachris
- National and Kapodistrian University of Athens and Athens Heart Center, Athens, Greece
| | - Panagiota Pietri
- National and Kapodistrian University of Athens and Athens Heart Center, Athens, Greece
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31
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Emami H, Takx RAP, Mayrhofer T, Janjua S, Park J, Pursnani A, Tawakol A, Lu MT, Ferencik M, Hoffmann U. Nonobstructive Coronary Artery Disease by Coronary CT Angiography Improves Risk Stratification and Allocation of Statin Therapy. JACC Cardiovasc Imaging 2017; 10:1031-1038. [PMID: 28330658 DOI: 10.1016/j.jcmg.2016.10.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/19/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study sought to determine prognostic value of nonobstructive coronary artery disease (CAD) for atherosclerotic cardiovascular disease (ASCVD) events and to determine whether incorporation of this information into the pooled cohort equation reclassifies recommendations for statin therapy as defined by the 2013 guidelines for cholesterol management of the American College of Cardiology and American Heart Association (ACC/AHA). BACKGROUND Detection of nonobstructive CAD by coronary computed tomography angiography may improve risk stratification and permit individualized and more appropriate allocation of statin therapy. METHODS This study determined the pooled hazard ratio of nonobstructive CAD for ASCVD events from published studies and incorporated this information into the ACC/AHA pooled cohort equation. The study calculated revised sex- and ethnicity-based 10-year ASCVD risk and determined boundaries corresponding to the original 7.5% risk for ASCVD events. It also assessed reclassification for statin eligibility by incorporating the results from meta-analysis to individual patients from a separate cohort. RESULTS This study included 2 studies (2,295 subjects; 66% male; prevalence of nonobstructive CAD, 47%; median follow-up, 49 months; 67 ASCVD events). The hazard ratio of nonobstructive CAD for ASCVD events was 3.2 (95% confidence interval: 1.5 to 6.7). Incorporation of this information into the pooled cohort equation resulted in reclassification toward statin eligibility in individuals with nonobstructive CAD, with an original ASCVD score of 3.0% and 5.9% or higher in African-American women and men and a score of 4.4% and 4.6% or higher in Caucasian women and men, respectively. The absence of nonobstructive CAD resulted in reclassification toward statin ineligibility if the original ASCVD score was as 10.0% and 17.9% or lower in African-American women and men and 13.7% and 14.3% or lower in Caucasian women and men, respectively. Reclassification is observed in 14% of patients. CONCLUSIONS Detection of nonobstructive CAD by coronary computed tomography angiography improves risk stratification and permits individualized and more appropriate allocation of statin therapy across sex and ethnicity groups.
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Affiliation(s)
- Hamed Emami
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Internal Medicine, Yale-New Haven Hospital, Yale Medical School, New Haven, Connecticut
| | - Richard A P Takx
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Sumbal Janjua
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jakob Park
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Amit Pursnani
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ahmed Tawakol
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael T Lu
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maros Ferencik
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Division of Cardiovascular Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Cheezum MK, Kim A, Bittencourt MS, Kassop D, Nissen A, Thomas DM, Nguyen B, Glynn RJ, Shah NR, Villines TC. Association of tobacco use and cessation with coronary atherosclerosis. Atherosclerosis 2016; 257:201-207. [PMID: 27993385 DOI: 10.1016/j.atherosclerosis.2016.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 11/15/2016] [Accepted: 11/15/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS The impact of tobacco use and cessation on atherogenesis remains unclear. We aimed to study the association of tobacco use and prior cessation with the presence, extent and severity of atherosclerosis on coronary computed tomographic angiography (CTA). METHODS We examined 1798 consecutive symptomatic patients without known coronary artery disease (CAD) referred for CTA, stratified by smoking status (never, current [within 30 days], or former [>30 days before CTA]). Plaque severity (none, <50%, ≥50% stenosis), composition (non-calcified [NCP], partially calcified [PCP], or calcified plaque [CP]), and segment involvement score (SIS) were visually graded. Multivariate analysis was performed, adjusting for CAD risk factors and cholesterol lowering medication use. RESULTS The median age of patients was 50 years [IQR:42-58] (61% male), with 74% never smokers, 12% current smokers, and 14% former smokers (median quit duration = 12 years [IQR:3-26]). Smoking exposure in former versus current smokers was 11 [IQR:5-25] and 10 [IQR:2-20] pack-years, respectively (p = 0.01). Compared to never smokers, current smokers demonstrated an increased odds ratio of all plaque types (adjusted OR: any NCP = 1.55 [95% CI 1.04-2.32], p = 0.03; any PCP = 1.61 [1.10-2.37], p = 0.02; any CP = 1.93 [1.32-2.81], p = 0.001), non-obstructive CAD (aOR = 1.47 [1.04, 2.07], p = 0.03), obstructive CAD (aOR = 1.81 [1.01-3.24], p = 0.047), and SIS > 4 (aOR = 1.60 [1.04-2.46], p = 0.03). Compared to current smoking, prior smoking cessation (≥12 years) was associated with a decreased odds ratio of any NCP (aOR = 0.42 [0.19-0.90], p = 0.03), CP (aOR = 0.43 [0.22-0.84], p = 0.02), and obstructive CAD (aOR = 0.40, [0.15-0.98], p = 0.048). CONCLUSIONS Current smoking is independently associated with the presence and extent of coronary plaque, and a higher risk of non-obstructive and obstructive CAD compared to never smoking. Prior smoking cessation correlated with improvements in CTA-identified plaque measures.
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Affiliation(s)
- Michael K Cheezum
- Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Alexander Kim
- Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Marcio S Bittencourt
- Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - David Kassop
- Department of Medicine (Cardiology Service), Womack Army Medical Center, Ft. Bragg, NC, USA
| | - Alexander Nissen
- Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Dustin M Thomas
- Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX, USA
| | - Binh Nguyen
- Department of Radiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Robert J Glynn
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Nishant R Shah
- Lifespan Cardiovascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Brown University Alpert School of Medicine, Providence, RI, USA
| | - Todd C Villines
- Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD, USA
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Ladapo JA, Hoffmann U, Lee KL, Coles A, Huang M, Mark DB, Dolor RJ, Pelberg RA, Budoff M, Sigurdsson G, Severance HW, Douglas PS. Changes in Medical Therapy and Lifestyle After Anatomical or Functional Testing for Coronary Artery Disease. J Am Heart Assoc 2016; 5:JAHA.116.003807. [PMID: 27733347 PMCID: PMC5121482 DOI: 10.1161/jaha.116.003807] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Diagnostic testing in the care of patients newly presenting with symptoms suggestive of coronary artery disease may influence risk factor management, independent of test type or test results. However, little is known about changes in medications and lifestyle after anatomical or functional testing. Methods and Results We examined what factors influenced preventive medical therapy and lifestyle practices at 60 days among 10 003 symptomatic patients (53% women; mean age 61 years) randomly assigned to anatomical testing with coronary computed tomographic angiography or functional testing (NCT01174550). We also assessed the association of preventive changes with major cardiovascular events. There were no differences in medications/lifestyle at baseline. At 60 days, relative to baseline, the computed tomographic angiography strategy was associated with a higher proportion of patients newly initiating aspirin (11.8% versus 7.8%), statins (12.7% versus 6.2%), and β‐blockers (8.1% versus 5.3%), compared to functional testing (P<0.0001 for each). No significant differences between computed tomographic angiography and functional testing strategies were observed for initiation of exercise, quitting smoking, or weight loss in overweight/obese patients, though overall prevalence of healthy eating was higher after computed tomographic angiography (P=0.002) while obese/overweight status was lower (P=0.040). Positive initial test results and revascularization demonstrated stronger associations with preventive medications and lifestyle than test type. Medication initiation was not associated with fewer cardiovascular events. Conclusions Positive initial test results and revascularization are primary drivers of changes in preventive medical and lifestyle practices, with test type making secondary contributions. However, substantial opportunities exist to further reduce cardiovascular risk. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01174550.
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Affiliation(s)
- Joseph A Ladapo
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA Departments of Medicine and Population Health, New York University School of Medicine, New York, NY
| | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Adrian Coles
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Megan Huang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Rowena J Dolor
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Williams MC, Hunter A, Shah ASV, Assi V, Lewis S, Smith J, Berry C, Boon NA, Clark E, Flather M, Forbes J, McLean S, Roditi G, van Beek EJR, Timmis AD, Newby DE. Use of Coronary Computed Tomographic Angiography to Guide Management of Patients With Coronary Disease. J Am Coll Cardiol 2016; 67:1759-1768. [PMID: 27081014 PMCID: PMC4829708 DOI: 10.1016/j.jacc.2016.02.026] [Citation(s) in RCA: 245] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND In a prospective, multicenter, randomized controlled trial, 4,146 patients were randomized to receive standard care or standard care plus coronary computed tomography angiography (CCTA). OBJECTIVES The purpose of this study was to explore the consequences of CCTA-assisted diagnosis on invasive coronary angiography, preventive treatments, and clinical outcomes. METHODS In post hoc analyses, we assessed changes in invasive coronary angiography, preventive treatments, and clinical outcomes using national electronic health records. RESULTS Despite similar overall rates (409 vs. 401; p = 0.451), invasive angiography was less likely to demonstrate normal coronary arteries (20 vs. 56; hazard ratios [HRs]: 0.39 [95% confidence interval (CI): 0.23 to 0.68]; p < 0.001) but more likely to show obstructive coronary artery disease (283 vs. 230; HR: 1.29 [95% CI: 1.08 to 1.55]; p = 0.005) in those allocated to CCTA. More preventive therapies (283 vs. 74; HR: 4.03 [95% CI: 3.12 to 5.20]; p < 0.001) were initiated after CCTA, with each drug commencing at a median of 48 to 52 days after clinic attendance. From the median time for preventive therapy initiation (50 days), fatal and nonfatal myocardial infarction was halved in patients allocated to CCTA compared with those assigned to standard care (17 vs. 34; HR: 0.50 [95% CI: 0.28 to 0.88]; p = 0.020). Cumulative 6-month costs were slightly higher with CCTA: difference $462 (95% CI: $303 to $621). CONCLUSIONS In patients with suspected angina due to coronary heart disease, CCTA leads to more appropriate use of invasive angiography and alterations in preventive therapies that were associated with a halving of fatal and non-fatal myocardial infarction. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590).
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Affiliation(s)
- Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Amanda Hunter
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Valentina Assi
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephanie Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Joel Smith
- Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Colin Berry
- Institute for Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nicholas A Boon
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Elizabeth Clark
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - John Forbes
- Health Research Institute, University of Limerick, Limerick, Ireland
| | | | - Giles Roditi
- Institute for Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Edwin J R van Beek
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Adam D Timmis
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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Fordyce CB, Newby DE, Douglas PS. Diagnostic Strategies for the Evaluation of Chest Pain: Clinical Implications From SCOT-HEART and PROMISE. J Am Coll Cardiol 2016; 67:843-52. [PMID: 26892420 DOI: 10.1016/j.jacc.2015.11.055] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/02/2015] [Accepted: 11/12/2015] [Indexed: 11/17/2022]
Abstract
SCOT-HEART (Scottish COmputed Tomography of the HEART) and PROMISE (PROspective Multicenter Imaging Study for Evaluation of chest pain) represent the 2 largest and most comprehensive cardiovascular imaging outcome trials in patients with stable chest pain and provide significant insights into patient diagnosis, management, and outcomes. These trials are particularly timely, given the well-recognized knowledge gaps and widespread use of noninvasive imaging. The overall goal of this review is to distill the data generated from these 2 pivotal trials to better inform the practicing clinician in the selection of noninvasive testing for stable chest pain. Similarities and differences between SCOT-HEART and PROMISE are highlighted, and clinical and practical implications are discussed. Both trials show that coronary computed tomography angiography should have a greater role in the diagnostic pathway of patients with stable chest pain.
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Affiliation(s)
| | - David E Newby
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, Edinburgh, United Kingdom
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Independent prognostic value of coronary artery calcium score and coronary computed tomography angiography in an outpatient cohort of low to intermediate risk chest pain patients. Neth Heart J 2016; 24:332-42. [PMID: 26879946 PMCID: PMC4840119 DOI: 10.1007/s12471-016-0819-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Limited studies report on the additional prognostic value of coronary computed tomography angiography (CCTA) and the coronary artery calcium score (CACS). Methods For a median of 637 days, 1551 outpatients with chest pain, without known coronary artery disease (CAD) and low or intermediate pre-test probability of CAD, were followed for major adverse cardiac events (MACE), defined as death, myocardial infarction or late revascularisation. Cox proportional hazard regression was used to evaluate the independent prognostic value of CCTA and CACS. Results MACE occurred in 23 patients (1.5 %): death (3, 0.2 %), myocardial infarction (4, 0.3 %) and late revascularisation (16, 1.3 %). Multivariate analysis showed an independent prognostic value of CCTA (p < 0.001), CACS of 100–400 (p = 0.035) and CACS of > 400 (p = 0.021). CCTA showed obstructive CAD in 3.1 % of patients with CACS = 0. No events occurred in patients with CACS = 0 without obstructive CAD at CCTA, whereas 2/23 patients (9 %) with CACS = 0 with obstructive CAD had a MACE. Conclusions Our study shows that both CCTA and higher CACS categories have independent prognostic value in chest pain patients with low to intermediate pre-test probability of obstructive CAD, in which CCTA is appropriate. Furthermore a non-negligible amount of patients with CACS = 0 have obstructive CAD at CCTA. CCTA can be used in these patients to identify those at risk for MACE.
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Rodriguez-Granillo GA, Carrascosa P, Bruining N, Waksman R, Garcia-Garcia HM. Defining the non-vulnerable and vulnerable patients with computed tomography coronary angiography: evaluation of atherosclerotic plaque burden and composition. Eur Heart J Cardiovasc Imaging 2016; 17:481-91. [PMID: 26903599 DOI: 10.1093/ehjci/jew012] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/13/2016] [Indexed: 12/11/2022] Open
Abstract
The shift from coronary plaque stability to plaque instability remains poorly understood despite enormous efforts and expenditures have been assigned to the study of the subject. On the other hand, there have been serious advances in imaging helping us to characterizenon-vulnerable patients The latter has much more value in the clinical decision-making process since it provides high certainty that the patient's probability of a future acute event is low and treatment decisions should be made accordingly. Although coronary plaque rupture is still recognized as the main source of acute thrombotic events, numerous studies have shown that the prediction of events on an individual basis is far more complex and demands a more open approach aimed at characterizing patient risk rather than assessing the risk of thrombosis of a single plaque. Computed tomography coronary angiography (CTCA) has the ability to evaluate non-invasively the extent, burden, severity, and characteristics of coronary artery disease (CAD) and has a close relationship to intravascular ultrasound. On the basis of an excellent negative predictive value with an annualized event rate of ∼0.20% assessed over more than 6000 patients, thus providing a 5-year warranty period, CTCA has been identified as the finest non-invasive tool to exclude CAD. This means that CTCA is able to reliably characterize the non-vulnerable patient. Conversely, in the past few years, several studies have attempted to establish CTCA-derived predictors of acute coronary syndromes, both from a lesion level and a patient level basis with very low positive predictive value, thus questioning the vulnerable patient/plaque concept.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
| | - Nico Bruining
- Thoraxcenter, Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Ron Waksman
- MedStar Washington Hospital Center, 110 Irving St., NW, Suite 4B-1, Washington, DC 20010, USA
| | - Hector M Garcia-Garcia
- MedStar Washington Hospital Center, 110 Irving St., NW, Suite 4B-1, Washington, DC 20010, USA
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Okahara A, Sadamatsu K, Matsuura T, Koga Y, Mine D, Yoshida K. Coronary Artery Disease Screening With Carotid Ultrasound Examination by a Primary Care Physician. Cardiol Res 2016; 7:9-16. [PMID: 28197263 PMCID: PMC5295529 DOI: 10.14740/cr456w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2016] [Indexed: 01/18/2023] Open
Abstract
Background In this study, we investigated the feasibility of primary care physicians using carotid ultrasound to perform coronary artery disease screening in asymptomatic patients with multiple coronary risk factors. Methods We retrospectively collected the data of 135 consecutive asymptomatic patients (mean age: 68.5 ± 8.4 years; male, 75%) who were referred to our institution due to abnormal findings on a carotid ultrasound performed by a primary care physician and who underwent coronary computed tomography angiography. Results The mean number of risk factors was 4.1 ± 1.2 and the mean intima-media thickness was 2.00 ± 0.63 mm. Mild (≤ 50%), moderate (51-75%), and severe (> 76%) coronary stenosis was observed in 54 (40%), 27 (20%), and 25 patients (19%), respectively, while no plaque was found in 24 patients (18%), and five patients (4%) could not be evaluated due to calcification. Consequently, coronary angiography was performed in 56 (41%) patients and coronary intervention was required in 31 patients (23%). A multivariate logistic regression analysis demonstrated that the ratio of low-density lipoprotein cholesterol levels to high-density lipoprotein cholesterol levels, the use of calcium channel blockers and the value of the diastolic blood pressure were related to > 50% coronary stenosis. Conclusions The use of carotid ultrasound in the coronary artery disease screening by primary care physicians resulted in a high prevalence of coronary artery disease and high probabilities of coronary angiography and revascularization, and thus it is considered to be a useful and feasible strategy for the screening of asymptomatic patients.
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Affiliation(s)
- Arihide Okahara
- Department of Cardiology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Kenji Sadamatsu
- Department of Cardiology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Taku Matsuura
- Department of Cardiology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Yasuaki Koga
- Department of Cardiology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Daigo Mine
- Department of Cardiology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Keiki Yoshida
- Department of Cardiology, Saga-Ken Medical Centre Koseikan, Saga, Japan
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Use of Coronary Computed Tomographic Angiography Findings to Modify Statin and Aspirin Prescription in Patients With Acute Chest Pain. Am J Cardiol 2016; 117:319-24. [PMID: 26762723 DOI: 10.1016/j.amjcard.2015.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/30/2015] [Accepted: 10/30/2015] [Indexed: 01/02/2023]
Abstract
Coronary CT angiography (CCTA) is used in patients with low-intermediate chest pain presenting to the emergency department for its reliability in excluding acute coronary syndrome (ACS). However, its influence on medication modification in this setting is unclear. We sought to determine whether knowledge of CCTA-based coronary artery disease (CAD) was associated with change in statin and aspirin prescription. We used the CCTA arm of the Rule Out Myocardial Infarction using Computed Angiographic Tomography II multicenter, randomized control trial (R-II) and comparison cohort from the observational Rule Out Myocardial Infarction using Computed Angiographic Tomography I cohort (R-I). In R-II, subjects were randomly assigned to CCTA to guide decision making, whereas in R-I patients underwent CCTA with results blinded to caregivers and managed according to standard care. Our final cohort consisted of 277 subjects from R-I and 370 from R-II. ACS rate was similar (6.9% vs 6.2% respectively, p = 0.75). For subjects with CCTA-detected obstructive CAD without ACS, initiation of statin was significantly greater after disclosure of CCTA results (0% in R-I vs 20% in R-II, p = 0.009). Conversely, for subjects without CCTA-detected CAD, aspirin prescription was lower with disclosure of CCTA results (16% in R-I vs 4.8% in R-II, p = 0.001). However, only 68% of subjects in R-II with obstructive CAD were discharged on statin and 65% on aspirin. In conclusion, physician knowledge of CCTA results leads to improved alignment of aspirin and statin with the presence and severity of CAD although still many patients with CCTA-detected CAD are not discharged on aspirin or statin. Our findings suggest opportunity for practice improvement when CCTA is performed in the emergency department.
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Fordyce CB, Douglas PS. Optimal non-invasive imaging test selection for the diagnosis of ischaemic heart disease. Heart 2016; 102:555-64. [DOI: 10.1136/heartjnl-2015-307764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Cheezum MK, Subramaniyam PS, Bittencourt MS, Hulten EA, Ghoshhajra BB, Shah NR, Forman DE, Hainer J, Leavitt M, Padmanabhan R, Skali H, Dorbala S, Hoffmann U, Abbara S, Di Carli MF, Gewirtz H, Blankstein R. Prognostic value of coronary CTA vs. exercise treadmill testing: results from the Partners registry. Eur Heart J Cardiovasc Imaging 2015; 16:1338-46. [PMID: 25899714 PMCID: PMC4668770 DOI: 10.1093/ehjci/jev087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 03/02/2015] [Accepted: 03/18/2015] [Indexed: 12/25/2022] Open
Abstract
AIMS We sought to compare the complementary prognostic value of exercise treadmill testing (ETT) and coronary computed tomographic angiography (CTA) among patients referred for both exams. METHODS AND RESULTS We studied 582 patients without known coronary artery disease (CAD) who were clinically referred for ETT and CTA within 6 months. Patients were followed for cardiovascular (CV) death, non-fatal myocardial infarction (MI), or late revascularization (>90 days), stratified by Duke Treadmill Score (DTS) and CAD severity (≥50% stenosis). Mean age was 54 ± 13 years (63% male). In median follow-up of 40 months, there were 3 CV deaths, 7 non-fatal MIs, and 26 late revascularizations. ETT was inconclusive in 23%, positive in 31%, and negative in 46%. CTA demonstrated no CAD in 37%, non-obstructive CAD in 28%, and obstructive CAD in 35%. Among low-risk ETT patients (n = 326), there were 3 MI, 10 late revascularizations, and the frequent presence of non-obstructive (32%, n = 105) and obstructive CAD (27%, n = 88). When present, ETT features (i.e., angina, DTS, ischaemic electrocardiogram changes, and exercise capacity) individually failed to predict CV death/MI after adjustment for Morise score. Conversely, both obstructive CAD [HR 4.9 (1.0-23.3), P = 0.048] and CAD extent by segment involvement score >4 [HR 3.9 (1.0-15.2), P = 0.049] predicted increased risk for CV death or MI. CONCLUSION Patients with a low-risk ETT have an excellent prognosis at 40 months, despite the frequent presence of non-obstructive (32%) and obstructive (27%) CAD. In patients with an intermediate- to high-risk ETT (DTS <5), CTA can provide incremental risk stratification for future CV events.
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Affiliation(s)
- Michael K Cheezum
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Prem Srinivas Subramaniyam
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcio S Bittencourt
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil
| | - Edward A Hulten
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nishant R Shah
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Daniel E Forman
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Jon Hainer
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Marcia Leavitt
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ram Padmanabhan
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hicham Skali
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Sharmila Dorbala
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Suhny Abbara
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcelo F Di Carli
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
| | - Henry Gewirtz
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA
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Naue VM, Camargo G, Sabioni LR, Lima RDSL, Derenne ME, Lorenzo ARD, Freire MDC, Azevedo Filho CF, Resende ES, Gottlieb I. Changes in Medical Management after Coronary CT Angiography. Arq Bras Cardiol 2015; 105:410-7. [PMID: 26559988 PMCID: PMC4633005 DOI: 10.5935/abc.20150088] [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: 08/23/2014] [Accepted: 05/06/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction Coronary computed tomography angiography (CCTA) allows for non-invasive coronary
artery disease (CAD) phenotyping. There are still some uncertainties regarding the
impact this knowledge has on the clinical care of patients. Objective To determine whether CAD phenotyping by CCTA influences clinical decision making
by the prescription of cardiovascular drugs and their impact on non-LDL
cholesterol (NLDLC) levels. Methods We analysed consecutive patients from 2008 to 2011 submitted to CCTA without
previous diagnosis of CAD that had two serial measures of NLDLC, one up to 3
months before CCTA and the second from 3 to 6 months after. Results A total of 97 patients were included, of which 69% were men, mean age 64 ±
12 years. CCTA revealed that 18 (18%) patients had no CAD, 38 (39%) had
non-obstructive (< 50%) lesions and 41 (42%) had at least one obstructive
≥ 50% lesion. NLDLC was similar at baseline between the grups (138 ±
52 mg/dL vs. 135 ± 42 mg/dL vs. 131 ± 44 mg/dL, respectively, p =
0.32). We found significative reduction in NLDLC among patients with obstrctive
lesions (-18%, p = 0.001). We also found a positive relationship between clinical
treatment intensification with aspirin and cholesterol reducing drugs and the
severity of CAD. Conclusion Our data suggest that CCTA results were used for cardiovascular clinical treatment
titration, with especial intensification seen in patients with obstructive
≥50% CAD.
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Prevalence and Implications of Subclinical Coronary Artery Disease in Patients With Atrial Fibrillation. Am J Cardiol 2015; 116:1219-23. [PMID: 26279110 DOI: 10.1016/j.amjcard.2015.07.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/12/2015] [Accepted: 07/12/2015] [Indexed: 11/20/2022]
Abstract
The objective of this study was to examine prevalence and clinical implications of subclinical coronary artery disease (CAD) detected by coronary artery calcium score (CACS) testing in patients with atrial fibrillation (AF). CACS was assessed in patients without history of CAD undergoing catheter ablation of AF. Age- and gender-matched patients with normal sinus rhythm (NSR) presenting with chest pain served as controls. Predicted arterial age using the Multi-Ethnic Study of Atherosclerosis registry was also compared to the chronologic age. A total of 860 patients (430 AF and 430 NSR, age 63 ± 10 years, 65% men) were included. Subclinical CAD prevalence (CACS >0) was 74% (319 of 430) in the AF group. Compared to the patients with NSR, patients with AF had higher prevalence of Subclinical CAD (74% vs 63%; p <0.001). In multivariate analysis, AF was independently associated with Subclinical CAD (hazard ratio 1.60; p = 0.002) but only with persistent AF (hazard ratio 2.28; p <0.001). Predicted arterial age was greater than chronologic age in patients with AF (69 ± 12 vs 64 ± 9 years). CACS-diagnosed subclinical CAD identified new potential candidates for statin therapy (12%; 33 of 267) and for oral anticoagulation (19%; 40 of 206) by addition of subclinical CAD to the CHA2DS2-VASc scores. In conclusion, in patients without known history of CAD, prevalence of subclinical CAD was significantly higher in those with persistent AF than those with NSR. AF was associated with subclinical CAD independently and complimentarily to clinical risk factors. Identifying subclinical CAD has potential clinical indications for prevention of CAD progression and stroke.
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Bom MJ, van der Zee PM, Cornel JH, van der Zant FM, Knol RJJ. Diagnostic and Therapeutic Usefulness of Coronary Computed Tomography Angiography in Out-Clinic Patients Referred for Chest Pain. Am J Cardiol 2015; 116:30-6. [PMID: 25933737 DOI: 10.1016/j.amjcard.2015.03.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 12/18/2022]
Abstract
Coronary computed tomography angiography (CCTA) is widely used to exclude coronary artery disease (CAD) in patients with low-to-intermediate pretest probability (PTP) of obstructive CAD. The aim of our study was to investigate the reclassification by CCTA and the implications of CCTA results on management because limited studies exist on these subjects; 1,560 patients with chest pain without a history of CAD and with low or intermediate PTP of CAD referred for CCTA from the out-patient clinic were prospectively included. PTP was defined by the Duke Clinical Score as either low (<15%), low-intermediate (15% to 50%), or high-intermediate (50% to 85%). Distribution of CCTA results among the categories of PTP of CAD and the influence of CCTA results on management were analyzed. CCTA revealed obstructive CAD in 7%, 15%, and 23% of cases, in patients with low, low-intermediate, and high-intermediate PTP, respectively; 855 of 1,031 patients (83%) with intermediate PTP of CAD showed no obstructive CAD on CCTA and were consequently reclassified. Management changes after CCTA occurred in 689 patients (44%). In 633 patients (41%), medication was altered and 135 (9%) were referred for invasive coronary angiography. Treatment with statin was initiated in 442 (28%) and stopped in 71 patients (5%). Aspirin was initiated in 192 (12%) and stopped in 139 patients (9%). In conclusion, in a routine clinical cohort, CCTA resulted in reclassification in most patients. Furthermore, our study suggests that the Duke Clinical Score overestimates the probability of obstructive CAD compared with CCTA findings. Finally, CCTA results have implications on patient management, with medication changes in 41% of patients.
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Affiliation(s)
- Michiel J Bom
- Department of Cardiology, Medical Center Alkmaar, Alkmaar, The Netherlands.
| | | | - Jan H Cornel
- Department of Cardiology, Medical Center Alkmaar, Alkmaar, The Netherlands
| | - Friso M van der Zant
- Department of Nuclear Medicine, Medical Center Alkmaar, Alkmaar, The Netherlands
| | - Remco J J Knol
- Department of Nuclear Medicine, Medical Center Alkmaar, Alkmaar, The Netherlands
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Association between Aspirin Therapy and Clinical Outcomes in Patients with Non-Obstructive Coronary Artery Disease: A Cohort Study. PLoS One 2015; 10:e0129584. [PMID: 26035823 PMCID: PMC4452779 DOI: 10.1371/journal.pone.0129584] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/11/2015] [Indexed: 01/06/2023] Open
Abstract
Background Presence of non-obstructive coronary artery disease (CAD) is associated with increased prescription of cardiovascular preventive medications including aspirin. However, the association between aspirin therapy with all-cause mortality and coronary revascularization in this population has not been investigated. Methods and Findings Among the cohort of individuals who underwent coronary computed tomography angiography (CCTA) from 2007 to 2011, 8372 consecutive patients with non-obstructive CAD (1-49% stenosis) were identified. Patients with statin or aspirin prescription before CCTA, and those with history of revascularization before CCTA were excluded. We analyzed the differences of all-cause mortality and a composite of mortality and late coronary revascularization (>90 days after CCTA) between aspirin users (n=3751; 44.8%) and non-users. During a median of 828 (interquartile range 385–1,342) days of follow-up, 221 (2.6%) mortality cases and 295 (3.5%) cases of composite endpoint were observed. Annualized mortality rates were 0.97% in aspirin users versus 1.28% in non-users, and annualized rates of composite endpoint were 1.56% versus 1.48%, respectively. Aspirin therapy was associated with significantly lower risk of all-cause mortality (adjusted HR 0.649; 95% CI 0.492–0.857; p=0.0023), but not with the composite endpoint (adjusted HR 0.841; 95% CI 0.662–1.069; p=0.1577). Association between aspirin and lower all-cause mortality was limited to patients with age ≥65 years, diabetes, hypertension, decreased renal function, and higher levels of coronary artery calcium score, low-density lipoprotein cholesterol and high-sensitivity C-reactive protein. Conclusions Among the patients with non-obstructive CAD documented by CCTA, aspirin is associated with lower all-cause mortality only in those with higher risk.
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Thomas DM, Divakaran S, Villines TC, Nasir K, Shah NR, Slim AM, Blankstein R, Cheezum MK. Management of Coronary Artery Calcium and Coronary CTA Findings. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8:18. [PMID: 25960825 PMCID: PMC4412516 DOI: 10.1007/s12410-015-9334-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient's risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (<50 % stenosis), observational data support consideration of statin use/intensification in patients with extensive plaque (at least four coronary segments involved) and patients with high-risk plaque features. In patients with both nonobstructive and obstructive CAD, multiple studies have now demonstrated an ability of CTA to guide management and improve CAD risk factor control. Still, significant under-treatment of cardiovascular risk factors and high-risk image findings remain, among concerns that CTA may increase invasive angiography and revascularization. To fully realize the impact of atherosclerosis imaging for ASCVD prevention, patient engagement in lifestyle changes and the modification of ASCVD risk factors remain the foundation of care. This review provides an overview of available data and recommendations in the management of CAC and CTA findings.
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Affiliation(s)
- Dustin M. Thomas
- />Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX USA
| | - Sanjay Divakaran
- />Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Todd C. Villines
- />Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Khurram Nasir
- />Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL USA
| | - Nishant R. Shah
- />Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA USA
| | - Ahmad M. Slim
- />Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX USA
| | - Ron Blankstein
- />Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA USA
| | - Michael K. Cheezum
- />Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Boston, MA USA
- />Non-invasive Cardiovascular Imaging Program, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 USA
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Pursnani A, Schlett CL, Mayrhofer T, Celeng C, Zakroysky P, Bamberg F, Nagurney JT, Truong QA, Hoffmann U. Potential for coronary CT angiography to tailor medical therapy beyond preventive guideline-based recommendations: insights from the ROMICAT I trial. J Cardiovasc Comput Tomogr 2015; 9:193-201. [PMID: 25846248 DOI: 10.1016/j.jcct.2015.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 01/05/2015] [Accepted: 02/14/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Coronary CT angiography (CCTA) is used in the emergency department to rule out acute coronary syndrome in low-intermediate risk patients. OBJECTIVES We evaluated the potential of CCTA to tailor aspirin (ASA) and statin therapy in acute chest pain patients. METHODS We included all patients in the ROMICAT I trial who underwent CCTA before admission. Results of CCTA were blinded to caretakers. We documented ASA and statin therapy at admission and discharge and determined change in medications during hospitalization, agreement of discharge medications with contemporaneous guidelines, and agreement with the presence and severity of coronary artery disease (CAD) as determined by CCTA. RESULTS We included 368 patients (53 ± 12 years; 61% male). Baseline medical therapy at presentation included 27% on ASA and 24% on statin. Most patients who qualified for secondary prevention were on ASA and statin therapy at discharge (95% and 80%, respectively), whereas among those qualifying for primary prevention therapy, only 59% of patients were on aspirin and 33% were on statin at discharge. Excluding secondary prevention patients, among those with CCTA-detected CAD, only 66/131 (50%) were on ASA at discharge and only 53/131 (40%) were on statin. Conversely, in those without CCTA-detected CAD, 54/156 (35%) were on ASA and 20/151 (13%) were on statin at discharge. CONCLUSION There are significant discrepancies between discharge prescription of statin and ASA with the presence and extent of CAD. CCTA presents an efficient opportunity to tailor medical therapy to CAD in patients undergoing CCTA as part of their acute chest pain evaluation.
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Affiliation(s)
- Amit Pursnani
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA; Cardiology Division, Evanston Hospital, Walgreen Building 3rd Floor, 2650 Ridge Ave, Evanston, IL 60201, USA.
| | - Christopher L Schlett
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Csilla Celeng
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Pearl Zakroysky
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fabian Bamberg
- Department of Clinical Radiology, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Quynh A Truong
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital, Weill Cornell Medical College, NY, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
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Hwang IC, Jeon JY, Kim Y, Kim HM, Yoon YE, Lee SP, Kim HK, Sohn DW, Sung J, Kim YJ. Statin therapy is associated with lower all-cause mortality in patients with non-obstructive coronary artery disease. Atherosclerosis 2015; 239:335-42. [PMID: 25682032 DOI: 10.1016/j.atherosclerosis.2015.01.036] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 01/07/2015] [Accepted: 01/25/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Non-obstructive coronary artery disease (CAD) is a frequent clinical condition and is associated with an increase in cardiovascular events. However, appropriate medical therapy for this population is not known. We investigated the association between statin use and risk of all-cause mortality and coronary revascularization in patients with non-obstructive CAD. METHODS From 2007 to 2011, we identified 8372 consecutive patients with non-obstructive CAD (1-49% stenosis) documented by coronary computed tomography angiography (CCTA) from 3 medical centers. Patients with statins or aspirin use before CCTA, and a history of revascularization before initial CCTA were excluded. All-cause mortality and a composite of mortality and late coronary revascularization (>90 days after CCTA) were analyzed according to the use of statins. RESULTS Mean age of the study population was 61.4 ± 10.9 years and 70.3% were male. Statins were prescribed to 1983 (23.7%) patients. During 828 days of follow-up (IQR 385-1342), 221 (2.6%) cases of all-cause mortality and 295 (3.5%) cases of the composite endpoint were observed. Statin therapy was associated with lower risks of all-cause mortality (adjusted HR 0.397; 95% CI 0.262-0.602; p < 0.0001) and composite endpoint (adjusted HR 0.430; 95% CI 0.310-0.597; p < 0.0001). Association between statin therapy and better clinical outcomes was regardless of age, sex, presence of hypertension or diabetes, coronary artery calcium score, low-density lipoprotein cholesterol levels, high-sensitivity C-reactive protein levels, or glomerular filtration rate. CONCLUSIONS Statin therapy was associated with a lower risk of all-cause mortality in patients with non-obstructive CAD documented by CCTA, regardless of combined clinical risk factors.
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Affiliation(s)
- In-Chang Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joo-Yeong Jeon
- Department of Statistics, Sungkyunkwan University, Seoul, Republic of Korea
| | - Younhee Kim
- Institute of Health and Environment, School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Hyue Mee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Kwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dae-Won Sohn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jidong Sung
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Yong-Jin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea.
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Divakaran S, Cheezum MK, Hulten EA, Bittencourt MS, Silverman MG, Nasir K, Blankstein R. Use of cardiac CT and calcium scoring for detecting coronary plaque: implications on prognosis and patient management. Br J Radiol 2014; 88:20140594. [PMID: 25494818 DOI: 10.1259/bjr.20140594] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Clinicians often use risk factor-based calculators to estimate an individual's risk of developing cardiovascular disease. Non-invasive cardiovascular imaging, particularly coronary artery calcium (CAC) scoring and coronary CT angiography (CTA), allows for direct visualization of coronary atherosclerosis. Among patients without prior coronary artery disease, studies examining CAC and coronary CTA have consistently shown that the presence, extent and severity of coronary atherosclerosis provide additional prognostic information for patients beyond risk factor-based scores alone. This review will highlight the basics of CAC scoring and coronary CTA and discuss their role in impacting patient prognosis and management.
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Affiliation(s)
- S Divakaran
- 1 Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Cheezum MK, Blankstein R. Coronary computed tomographic angiography: its role in emergency department triage. Circulation 2014; 130:2052-6. [PMID: 25446058 DOI: 10.1161/circulationaha.114.009648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Michael K Cheezum
- From the Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston MA
| | - Ron Blankstein
- From the Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston MA.
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