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Marchi E, Muraca I, Berteotti M, Gori AM, Valenti R, Marcucci R. Adenosine in Interventional Cardiology: Physiopathologic and Pharmacologic Effects in Coronary Artery Disease. Int J Mol Sci 2024; 25:5852. [PMID: 38892037 PMCID: PMC11172110 DOI: 10.3390/ijms25115852] [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: 04/30/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
This review article focuses on the role of adenosine in coronary artery disease (CAD) diagnosis and treatment. Adenosine, an endogenous purine nucleoside, plays crucial roles in cardiovascular physiology and pathology. Its release and effects, mediated by specific receptors, influence vasomotor function, blood pressure regulation, heart rate, and platelet activity. Adenosine therapeutic effects include treatment of the no-reflow phenomenon and paroxysmal supraventricular tachycardia. The production of adenosine involves complex cellular pathways, with extracellular and intracellular synthesis mechanisms. Adenosine's rapid metabolism underscores its short half-life and physiological turnover. Furthermore, adenosine's involvement in side effects of antiplatelet therapy, particularly ticagrelor and cangrelor, highlights its clinical significance. Moreover, adenosine serves as a valuable tool in CAD diagnosis, aiding stress testing modalities and guiding intracoronary physiological assessments. Its use in assessing epicardial stenosis and microvascular dysfunction is pivotal for treatment decisions. Overall, understanding adenosine's mechanisms and clinical implications is essential for optimizing CAD management strategies, encompassing both therapeutic interventions and diagnostic approaches.
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Affiliation(s)
- Enrico Marchi
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, Careggi University Hospital, University of Florence, 50134 Florence, Italy
| | - Iacopo Muraca
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy
| | - Martina Berteotti
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy (R.M.)
| | - Anna Maria Gori
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy (R.M.)
| | - Renato Valenti
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy
| | - Rossella Marcucci
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy (R.M.)
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Antoniadis M, Blum M, Ussat M, Laufs U, Lenk K. Standardized angiographic projections allow evaluation of coronary artery side branches with quantitative flow ratio (QFR). IJC HEART & VASCULATURE 2024; 50:101349. [PMID: 38322018 PMCID: PMC10844669 DOI: 10.1016/j.ijcha.2024.101349] [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: 11/06/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/08/2024]
Abstract
Quantitative flow ratio (QFR) is a novel, software-based noninvasive method for the quantitative evaluation of coronary physiology. QFR results correlate with invasive FFR measurements in the three main epicardial coronary arteries. However, QFR data for the evaluation of coronary side branches (SB) are scarce. The evaluation of QFR-performance of SB was retrospective and prospective. Eighty-seven patients with suspected chronic coronary syndrome, who received angiography using routine core lab projections, were retrospectively analyzed. On the second part 37 patients, who received angiography using recommended standardized coronary angiography projections, were prospectively analyzed. Quantitative analysis was performed for SB with a maximum lumen diameter proximal of ≥2 mm based on quantitative coronary angiography (QCA) by two certified experts with the software QAngio XA 3D 3.2. Using routine projections, QFR computation in 55 % of the SB were obtained (123 out of 224). Using standardized projections, 85 % of SB were computed by QFR (64 out of 75; p < 0.001 vs routine projections). The fluoroscopy time for recommended projections was not significantly different as opposed to routine projections (3.75 ± 2.2 vs. 4.58 ± 3.00 min, p = 2.6986). Using the standardized projections was associated with a higher amount of contrast medium (53.44 ± 24.23 vs. 87.95 ± 43.73 ml, p < 0.01), longer overall procedure time (23.23 ± 16.35 vs. 36.14 ± 17.21 min, p < 0.01) and a higher dose area product (1152.28 ± 576.70 vs. 2540.68 ± 1774.07 cGycm2, p < 0.01). Our study shows that the blood flow of the vast majority of coronary SB can be determined non-invasively by QFR in addition to the main epicardial coronary arteries when standardized projections are used.
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Affiliation(s)
| | | | - M. Ussat
- Department of Cardiology, Leipzig University Hospital, Leipzig, Germany
| | - U. Laufs
- Department of Cardiology, Leipzig University Hospital, Leipzig, Germany
| | - K. Lenk
- Department of Cardiology, Leipzig University Hospital, Leipzig, Germany
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Davis EF, Crousillat DR, Peteiro J, Lopez-Sendon J, Senior R, Shapiro MD, Pellikka PA, Lyubarova R, Alfakih K, Abdul-Nour K, Anthopolos R, Xu Y, Kunichoff DM, Fleg JL, Spertus JA, Hochman J, Maron D, Picard MH, Reynolds HR. Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA Study. J Am Soc Echocardiogr 2024; 37:89-99. [PMID: 37722490 PMCID: PMC10842002 DOI: 10.1016/j.echo.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA). OBJECTIVES To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA. METHODS Left ventricular GLS was calculated offline on resting SE images at enrollment (n = 144) and 1-year follow-up (n = 120) in the CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial screen failures with no obstructive CAD on computed tomography [CT] angiography) study, which enrolled participants with moderate or severe ischemia by local SE interpretation (≥3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) on coronary computed tomography angiography. RESULTS Global longitudinal strain values were normal in 83.3% at enrollment and 94.2% at follow-up. Global longitudinal strain values were not associated with a positive SE at enrollment (GLS = -21.5% positive SE vs GLS = -19.9% negative SE, P = .443) or follow-up (GLS = -23.2% positive SE vs GLS = -23.1% negative SE, P = .859). Significant change in GLS was not associated with positive SE in follow-up (P = .401). Regional strain was not associated with colocalizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β = 0.41; 95% CI, 0.16, 0.67; P = .002). CONCLUSIONS In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity, or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.
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Affiliation(s)
- Esther F Davis
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Victorian Heart Institute and Victorian Heart Hospital, Victoria, Australia
| | - Daniela R Crousillat
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, Florida; Department of Obstetrics and Gynecology, Tampa General-Heart and Vascular Institute, University of South Florida, Tampa, Florida
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña, CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Michael D Shapiro
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Rebecca Anthopolos
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Yifan Xu
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Dennis M Kunichoff
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Jerome L Fleg
- National Institute of Health-National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Judith Hochman
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - David Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Michael H Picard
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York.
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Lunardi M, Louvard Y, Lefèvre T, Stankovic G, Burzotta F, Kassab GS, Lassen JF, Darremont O, Garg S, Koo BK, Holm NR, Johnson TW, Pan M, Chatzizisis YS, Banning AP, Chieffo A, Dudek D, Hildick-Smith D, Garot J, Henry TD, Dangas G, Stone G, Krucoff MW, Cutlip D, Mehran R, Wijns W, Sharif F, Serruys PW, Onuma Y. Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations. EUROINTERVENTION 2023; 19:e807-e831. [PMID: 35583108 PMCID: PMC10687650 DOI: 10.4244/eij-e-22-00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.
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Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of -Ireland Galway, Galway, Ireland
- Division of Cardiology, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Yves Louvard
- Institut Cardiovasculaire Paris Sud, Massy, France
| | | | - Goran Stankovic
- Department of Cardiology, University Clinical Center of -Serbia and Faculty of Medicine, University of Belgrade, -Belgrade, -Serbia
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ghassan S Kassab
- California Medical Innovation Institute, San Diego, California, USA
| | - Jens F Lassen
- Department of Cardiology B, Odense Universitets Hospital and University of Southern Denmark, Odense C, Denmark
| | | | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Thomas W Johnson
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol NHSFT & University of Bristol, Bristol, United Kingdom
| | - Manuel Pan
- IMIBIC, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Yiannis S Chatzizisis
- Cardiovascular Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Alaide Chieffo
- Division of Cardiology, San Raffaele Hospital, Milan, Italy
| | - Dariusz Dudek
- Second Department of Cardiology Jagiellonian University Medical College, Krakow, Poland
| | | | - Jérome Garot
- Institut Cardiovasculaire Paris Sud, Massy, France
| | - Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, Ohio, USA
| | - George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregg Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mitchell W Krucoff
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Baim Institute for Clinical Research and Harvard Medical School, Boston, Massachusetts, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Wijns
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of -Ireland Galway, Galway, Ireland
- The Lambe Institute for Translational Medicine and CURAM, National University of Ireland Galway, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of -Ireland Galway, Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of -Ireland Galway, Galway, Ireland
- International Centre for Circulatory Health, NHLI, Imperial College, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of -Ireland Galway, Galway, Ireland
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Clerc OF, Frey SM, Honegger U, Amrein MLF, Caobelli F, Haaf P, Zellweger MJ. Coronary artery calcium score and pre-test probabilities as gatekeepers to predict and rule out perfusion defects in positron emission tomography. J Nucl Cardiol 2023; 30:2559-2573. [PMID: 37415007 PMCID: PMC10682222 DOI: 10.1007/s12350-023-03322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/02/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Little is known about the gatekeeper performance of coronary artery calcium score (CACS) before myocardial perfusion positron emission tomography (PET), compared with updated pre-test probabilities from American and European guidelines (pre-test-AHA/ACC, pre-test-ESC). METHODS We enrolled participants without known coronary artery disease undergoing CACS and Rubidium-82 PET. Abnormal perfusion was defined as summed stress score ≥ 4. Using Bayes' formula, pre-test probabilities and CACS were combined into post-test probabilities. RESULTS We included 2050 participants (54% male, mean age 64.6 years) with median CACS 62 (IQR 0-380), pre-test-ESC 17% (11-26), pre-test-AHA/ACC 27% (16-44), and abnormal perfusion in 437 participants (21%). To predict abnormal perfusion, area under the curve of CACS was 0.81, pre-test-AHA/ACC 0.68, pre-test-ESC 0.69, post-test-AHA/ACC 0.80, and post-test-ESC 0.81 (P < 0.001 for CACS vs. each pre-test, and each post-test vs. pre-test). CACS = 0 had 97% negative predictive value (NPV), pre-test-AHA/ACC ≤ 5% 100%, pre-test-ESC ≤ 5% 98%, post-test-AHA/ACC ≤ 5% 98%, and post-test-ESC ≤ 5% 96%. Among participants, 26% had CACS = 0, 2% pre-test-AHA/ACC ≤ 5%, 7% pre-test-ESC ≤ 5%, 23% post-test-AHA/ACC ≤ 5%, and 33% post-test-ESC ≤ 5% (all P < 0.001). CONCLUSIONS CACS and post-test probabilities are excellent predictors of abnormal perfusion and can rule it out with very high NPV in a substantial proportion of participants. CACS and post-test probabilities may be used as gatekeepers before advanced imaging. Coronary artery calcium score (CACS) predicted abnormal perfusion (SSS ≥ 4) in myocardial positron emission tomography (PET) better than pre-test probabilities of coronary artery disease (CAD), while pre-test-AHA/ACC and pre-test-ESC performed similarly (left). Using Bayes' formula, pre-test-AHA/ACC or pre-test-ESC were combined with CACS into post-test probabilities (middle). This calculation reclassified a substantial proportion of participants to low probability of CAD (0-5%), not needing further imaging, as shown for AHA/ACC probabilities (2% with pre-test-AHA/ACC to 23% with post-test-AHA/ACC, P < 0.001, right). Very few participants with abnormal perfusion were classified under pre-test or post-test probabilities 0-5%, or under CACS 0. AUC: area under the curve. Pre-test-AHA/ACC: Pre-test probability of the American Heart Association/American College of Cardiology. Post-test-AHA/ACC: Post-test probability combining pre-test-AHA/ACC and CACS. Pre-test-ESC: Pre-test probability of the European Society of Cardiology. SSS: Summed stress score.
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Affiliation(s)
- Olivier F Clerc
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Simon M Frey
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ursina Honegger
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Melissa L F Amrein
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Federico Caobelli
- Department of Nuclear Medicine, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael J Zellweger
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.
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Sardu C, Trotta MC, Sasso FC, Sacra C, Carpinella G, Mauro C, Minicucci F, Calabrò P, D' Amico M, D' Ascenzo F, De Filippo O, Iannaccone M, Pizzi C, Paolisso G, Marfella R. SGLT2-inhibitors effects on the coronary fibrous cap thickness and MACEs in diabetic patients with inducible myocardial ischemia and multi vessels non-obstructive coronary artery stenosis. Cardiovasc Diabetol 2023; 22:80. [PMID: 37005586 PMCID: PMC10067292 DOI: 10.1186/s12933-023-01814-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 03/25/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Sodium-glucose transporter 2 inhibitors (SGLT2-I) could modulate atherosclerotic plaque progression, via down-regulation of inflammatory burden, and lead to reduction of major adverse cardiovascular events (MACEs) in type 2 diabetes mellitus (T2DM) patients with ischemic heart disease (IHD). T2DM patients with multivessel non-obstructive coronary stenosis (Mv-NOCS) have over-inflammation and over-lipids' plaque accumulation. This could reduce fibrous cap thickness (FCT), favoring plaque rupture and MACEs. Despite this, there is not conclusive data about the effects of SGLT2-I on atherosclerotic plaque phenotype and MACEs in Mv-NOCS patients with T2DM. Thus, in the current study, we evaluated SGLT2-I effects on Mv-NOCS patients with T2DM in terms of FCT increase, reduction of systemic and coronary plaque inflammation, and MACEs at 1 year of follow-up. METHODS In a multi-center study, we evaluated 369 T2DM patients with Mv-NOCS divided in 258 (69.9%) patients that did not receive the SGLT2-I therapy (Non-SGLT2-I users), and 111 (30.1%) patients that were treated with SGLT2-I therapy (SGLT2-I users) after percutaneous coronary intervention (PCI) and optical coherence tomography (OCT) evaluation. As the primary study endpoint, we evaluated the effects of SGLT2-I on FCT changes at 1 year of follow-up. As secondary endpoints, we evaluated at baseline and at 12 months follow-up the inflammatory systemic and plaque burden and rate of MACEs, and predictors of MACE through multivariable analysis. RESULTS At 6 and 12 months of follow-up, SGLT2-I users vs. Non-SGLT2-I users showed lower body mass index (BMI), glycemia, glycated hemoglobin, B-type natriuretic peptide, and inflammatory cells/molecules values (p < 0.05). SGLT2-I users vs. Non-SGLT2-I users, as evaluated by OCT, evidenced the highest values of minimum FCT, and lowest values of lipid arc degree and macrophage grade (p < 0.05). At the follow-up end, SGLT2-I users vs. Non-SGLT2-I users had a lower rate of MACEs [n 12 (10.8%) vs. n 57 (22.1%); p < 0.05]. Finally, Hb1Ac values (1.930, [CI 95%: 1.149-2.176]), macrophage grade (1.188, [CI 95%: 1.073-1.315]), and SGLT2-I therapy (0.342, [CI 95%: 0.180-0.651]) were independent predictors of MACEs at 1 year of follow-up. CONCLUSIONS SGLT2-I therapy may reduce about 65% the risk to have MACEs at 1 year of follow-up, via ameliorative effects on glucose homeostasis, and by the reduction of systemic inflammatory burden, and local effects on the atherosclerotic plaque inflammation, lipids' deposit, and FCT in Mv-NOCS patients with T2DM.
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Affiliation(s)
- Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138, Naples, Italy.
| | - Maria Consiglia Trotta
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138, Naples, Italy
| | - Cosimo Sacra
- Department of Cardiology, Gemelli Molise, Campobasso, Italy
| | | | - Ciro Mauro
- Department of Cardiology, Hospital Cardarelli, Naples, Italy
| | - Fabio Minicucci
- Department of Cardiology, San Leonardo Hospital, Naples, Italy
| | - Paolo Calabrò
- Department of Cardio-Thoracic and Respiratory Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Michele D' Amico
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fabrizio D' Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza", Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, "Città della Salute e della Scienza", Turin, Italy
| | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Carmine Pizzi
- Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, Bologna, Italy
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138, Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138, Naples, Italy
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7
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Zhang H, Sheng J, Li G, Liu F, Bian H, Niu X, Kang L. The value of CMR Left ventricular strain analysis in evaluating ICM. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:651-657. [PMID: 36460876 DOI: 10.1007/s10554-022-02761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/18/2022] [Indexed: 12/03/2022]
Abstract
The purpose of this article is to investigate the value of cardiac magnetic resonance imaging (CMR) derived left ventricular strain parameters in evaluation of ischemic cardiomyopathy (ICM). Thirty-one ICM patients and nineteen non-cardiomyopathy (non-CM) patients who performed CMR examinations during the same period were selected for this retrospective study. The basic clinical data, CMR left ventricular function parameters, left ventricular strain parameters were compared among the left ventricular ejection fraction (LVEF) preserved ICM group, the LVEF impaired ICM group and the non-CM group. The differences of MyoGCS (-21.9 ± 1.9 vs. -18.9 ± 2.7 P<0.001), MyoGLS (-20.8 ± 2.3 vs. -17.0 ± 2.9 P<0.001) and EndoGLS (-22.2 ± 3.1 vs. -17.6 ± 3.7 P<0.001) between LVEF preserved ICM group and non-CM group were statistically significant, while the differences of left heart function parameters between the two groups were not statistically significant (P > 0.05). The left ventricular strain analysis can be used to assess cardiac functional and morphological alterations in ICM patients prior to changes of left ventricular function parameters, which has high clinical significance.
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Affiliation(s)
- Houning Zhang
- Graduate School, Tianjin Medical University, Tianjin, China.,Department of Magnetic Resonance Imaging, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Jiaxi Sheng
- Graduate School, Tianjin Medical University, Tianjin, China.,Department of Endocrinology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Guoce Li
- Department of Magnetic Resonance Imaging, Cangzhou Central Hospital, Cangzhou, China
| | - Fenghai Liu
- Department of Magnetic Resonance Imaging, Cangzhou Central Hospital, Cangzhou, China
| | - Hao Bian
- Department of Magnetic Resonance Imaging, Cangzhou Central Hospital, Cangzhou, China
| | - Xiqing Niu
- Department of Magnetic Resonance Imaging, Cangzhou Central Hospital, Cangzhou, China
| | - Liqing Kang
- Graduate School, Tianjin Medical University, Tianjin, China. .,Department of Magnetic Resonance Imaging, Cangzhou Central Hospital, Cangzhou, China.
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Zhang Y, Liu MH, Zhang M, Wu GX, Liu J, Wang JZ, Sun XL, Jiang W, Wang D, Kang LM, Wu XY, Zou YB, Song L. Different clinical characteristics and outcomes of hypertrophic cardiomyopathy with and without hypertension: seeking the truth. J Geriatr Cardiol 2023; 20:109-120. [PMID: 36910243 PMCID: PMC9992951 DOI: 10.26599/1671-5411.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To determine the different clinical characteristics and outcomes of hypertrophic cardiomyopathy (HCM) patients with and without hypertension (HT). METHODS A total of 696 HCM patients were included in this study and all HCM diagnoses were confirmed by the genetic test. Patients were analyzed separately in the septal reduction therapy (SRT) cohort and the non-SRT cohort. The primary endpoint was cardiovascular death and the secondary endpoint was all-cause death. Outcome analyses were conducted to evaluate the associations between HT and outcomes in HCM. Medications before enrollment and at discharge were collected in the post-hoc analyses. RESULTS HCM patients without HT were younger, had a lower body mass index, were more likely to have a family history of HCM, and had a smaller left ventricular (LV) end-diastolic diameter than those with HT in both cohorts. A thicker LV wall, a higher level of N-terminal pro-B-type natriuretic peptide, and a higher extent of LV late gadolinium enhancement were additionally observed in patients without HT in the non-SRT cohort. The presence of HT did not alter the distribution pattern of late gadolinium enhancement, as well as the constituent ratio of eight disease-causing sarcomeric gene variants in both cohorts. Outcome analyses showed that in the non-SRT cohort, patients without HT had higher risks of cardiovascular death (HR = 2.537, P = 0.032) and all-cause death (HR = 3.309, P = 0.032). While such prognostic divergence was not observed in the SRT cohort. Further post-hoc analyses in the non-SRT cohort found that patients without HT received fewer non-dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers before enrollment and at discharge. CONCLUSIONS HCM patients without HT had worse clinical conditions and higher mortality than patients with HT overall, which may result from active medical therapy in HT patients. Active SRT may have a substantial de-risking effect on patients meeting the indications.
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Affiliation(s)
- Yu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming-Hao Liu
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mo Zhang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gui-Xin Wu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ji-Zheng Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Lu Sun
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen Jiang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Wang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lian-Ming Kang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Yi Wu
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Bao Zou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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9
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Li XM, Jiang L, Min CY, Yan WF, Shen MT, Liu XJ, Guo YK, Yang ZG. Myocardial Perfusion Imaging by Cardiovascular Magnetic Resonance: Research Progress and Current Implementation. Curr Probl Cardiol 2023; 48:101665. [PMID: 36828047 DOI: 10.1016/j.cpcardiol.2023.101665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
Cardiovascular diseases pose a significant health and economic burden worldwide, with coronary artery disease still recognized as a major problem. It is closely associated with hypertension, diabetes, obesity, smoking, lack of exercise, poor diet, and excessive alcohol consumption, which may lead to macro- and microvascular abnormalities in the heart. Coronary artery stenosis reduces the local supply of oxygen and nutrients to the myocardium and results in reduced levels of myocardial perfusion, which can lead to more severe conditions and irreversible damage to myocardial tissues. Therefore, accurate evaluation of myocardial perfusion abnormalities in patients with these risk factors is critical. As technology advances, magnetic resonance myocardial perfusion imaging has become more accurate at evaluating the myocardial microcirculation and has shown a powerful ability to detect myocardial ischemia. The purpose of this review is to summarize the principle, research progress of acquisition and analysis, and clinical implementation of cardiovascular magnetic resonance (CMR) myocardial perfusion imaging.
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Affiliation(s)
- Xue-Ming Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Laboratory of Cardiovascular Diseases, Regenerative Medicine Research Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Jiang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chen-Yan Min
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei-Feng Yan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Meng-Ting Shen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao-Jing Liu
- Laboratory of Cardiovascular Diseases, Regenerative Medicine Research Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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10
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Neglia D, Liga R, Gimelli A, Podlesnikar T, Cvijić M, Pontone G, Miglioranza MH, Guaricci AI, Seitun S, Clemente A, Sumin A, Vitola J, Saraste A, Paunonen C, Sia CH, Paleev F, Sade LE, Zamorano JL, Maroz-Vadalazhskaya N, Anagnostopoulos C, Macedo F, Knuuti J, Edvardsen T, Cosyns B, Petersen SE, Magne J, Laroche C, Berlè C, Popescu BA, Delgado V. Use of cardiac imaging in chronic coronary syndromes: the EURECA Imaging registry. Eur Heart J 2023; 44:142-158. [PMID: 36452988 DOI: 10.1093/eurheartj/ehac640] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 09/20/2022] [Accepted: 10/26/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The prospective, multicentre EURECA registry assessed the use of imaging and adoption of the European Society of Cardiology (ESC) Guidelines (GL) in patients with chronic coronary syndromes (CCS). METHODS Between May 2019 and March 2020, 5156 patients were recruited in 73 centres from 24 ESC member countries. The adoption of GL recommendations was evaluated according to clinical presentation and pre-test probability (PTP) of obstructive coronary artery disease (CAD). RESULTS The mean age of the population was 64 ± 11 years, 60% of patients were males, 42% had PTP >15%, 27% had previous CAD, and ejection fraction was <50% in 5%. Exercise ECG was performed in 32% of patients, stress imaging as the first choice in 40%, and computed tomography coronary angiography (CTCA) in 22%. Invasive coronary angiography (ICA) was the first or downstream test in 17% and 11%, respectively. Obstructive CAD was documented in 24% of patients, inducible ischaemia in 19%, and 13% of patients underwent revascularization. In 44% of patients, the overall diagnostic process did not adopt the GL. In these patients, referral to stress imaging (21% vs. 58%; P < 0.001) or CTCA (17% vs. 30%; P < 0.001) was less frequent, while exercise ECG (43% vs. 22%; P < 0.001) and ICA (48% vs. 15%; P < 0.001) were more frequently performed. The adoption of GL was associated with fewer ICA, higher proportion of diagnosis of obstructive CAD (60% vs. 39%, P < 0.001) and revascularization (54% vs. 37%, P < 0.001), higher quality of life, fewer additional testing, and longer times to late revascularization. CONCLUSIONS In patients with CCS, current clinical practice does not adopt GL recommendations on the use of diagnostic tests in a significant proportion of patients. When the diagnostic approach adopts GL recommendations, invasive procedures are less frequently used and the diagnostic yield and therapeutic utility are superior.
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Affiliation(s)
- Danilo Neglia
- Cardiovascular and Imaging Departments, Fondazione Toscana G. Monasterio, Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy
- Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Riccardo Liga
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell' Area Critica, University of Pisa, Via Savi 10, 56126 Pisa, Italy
- Dipartimento Cardiotoraco Vascolare, Azienda Ospedaliero-Universitaria Pisana, Via Paradisa, 2, 56124 Pisa, Italy
| | - Alessia Gimelli
- Cardiovascular and Imaging Departments, Fondazione Toscana G. Monasterio, Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy
| | - Tomaž Podlesnikar
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia
- Department of Cardiac Surgery, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
| | - Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška cesta 2, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via Carlo Parea, 4, 20138 Milano, Italy
| | - Marcelo Haertel Miglioranza
- EcoHaertel-Mae de Deus Hospital, R. José de Alencar, 286 - Menino Deus, Porto Alegre - RS, 90880-481, Brazil
- Federal University of Health Sciences of Porto Alegre (UFCSPA), R. Sarmento Leite, 245 - Centro Histórico, Porto Alegre - RS, 90050-17, Brazil
- Institute of Cardiology-University Foundation of Cardiology, R. Sarmento Leite, 245 - Centro Histórico, Porto Alegre - RS, 90050-170, Brazil
| | - Andrea Igoren Guaricci
- Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital 'Policlinico' of Bari, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Sara Seitun
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Largo Rosanna Benzi, 10, 16132 Genova, Italy
| | - Alberto Clemente
- Cardiovascular and Imaging Departments, Fondazione Toscana G. Monasterio, Via Giuseppe Moruzzi, 1, 56124 Pisa, Italy
| | - Alexey Sumin
- Federal State Budgetary Scientific Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Sosnoviy Blvd., 6, 650002 Kemerovo, Russian Federation
| | - João Vitola
- Quanta Diagnostico por Imagem, R. Alm. Tamandaré, 1000 - Alto da XV, Curitiba - PR, 80045-170, Brazil
| | - Antti Saraste
- Heart Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Christian Paunonen
- Heart Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Ching-Hui Sia
- National University Heart Centre Singapore, 5 Lower Kent Ridge Rd, 119074 Singapore, Singapore
| | - Filipp Paleev
- National Medical Research Center of Cardiology, 3-Ya Cherepkovskaya Ulitsa, 15A, 121552 Moscow, Russian Federation
| | - Leyla Elif Sade
- Department of Cardiology, University of Baskent, Yukarı Bahçelievler, Mareşal Fevzi Çakmak Cd. No: 45, 06490 Çankaya/Ankara, Turkey
| | - Jose Luis Zamorano
- Department of Cardiology, Ramon Y Cajal University Hospital, M-607, 9, 100, 28034 Madrid, Spain
| | - Natallia Maroz-Vadalazhskaya
- Department of General Practice, Division of Postgraduate Education, Belarusian State Medical University, Dzerzhinski Ave 83, 220083 Minsk, Belarus
| | - Constantinos Anagnostopoulos
- PET-CT Department & Preclinical Imaging Unit, Centre for Experimental Surgery, Clinical and Translational Research, Biomedical Research Foundation Academy of Athens, 4 Soranou Ephessiou Street, 115 27 Athens, Greece
| | - Filipe Macedo
- Cardiology Department, S João University Hospital, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, c/o Turku University Hospital, Kiinamyllynkatu 4-8, 20520 Turku, Finland
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Kirkeveien 166, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds vei 3, 0372 Oslo, Norway
| | - Bernard Cosyns
- Centrum voor Hart en Vaatziekten, Universtair Ziekenhuis Brussel, Av. du Laerbeek 101, 1090 Bruxelles, Belgium
- In Vivo Molecular and Cellular Imaging Center, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Steffen E Petersen
- Barts Heart Center, St. Bartholomew's Hospital, West Smithfield, W Smithfield, London EC1A 7BE, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Julien Magne
- Inserm Unit 1094 and IRD, Faculty of Medicine, Limoges University, 2 rue du Dr Marcland, 87025 Limoges, France
- Centre of Epidemiology, Biostatistic and Methodology of Research, University Hospital, Limoges, 2 Av. Martin Luther King, 87000 Limoges, France
- Department of Cardiology, Dupuytren-2 University Hospital, 16 rue Bernard Descottes, 87042 Limoges, France
| | - Cecile Laroche
- The European Society of Cardiology, The European Heart House, Sophia Antipolis Cedex, 2035 Rte des Colles, 06410 Biot, France
| | - Clara Berlè
- The European Society of Cardiology, The European Heart House, Sophia Antipolis Cedex, 2035 Rte des Colles, 06410 Biot, France
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Euroecolab, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Bulevardul Eroii Sanitari 8, 050474 București, Romania
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Heart Institute, Hospital University Germans Trias i Pujol, Carretera de Canyet, s/n, 08916, Badalona, Barcelona, Spain
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Rasmussen LD, Winther S, Eftekhari A, Karim SR, Westra J, Isaksen C, Brix L, Ejlersen JA, Murphy T, Milidonis X, Nyegaard M, Benovoy M, Johansen JK, Søndergaard HM, Hammid O, Mortensen J, Knudsen LL, Gormsen LC, Christiansen EH, Chiribiri A, Petersen SE, Böttcher M. Second-Line Myocardial Perfusion Imaging to Detect Obstructive Stenosis: Head-to-Head Comparison of CMR and PET. JACC Cardiovasc Imaging 2023; 16:642-655. [PMID: 36881421 DOI: 10.1016/j.jcmg.2022.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/25/2022] [Accepted: 11/14/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND Guidelines recommend verification of myocardial ischemia by selective second-line myocardial perfusion imaging (MPI) following a coronary computed tomography angiography (CTA) with suspected obstructive coronary artery disease (CAD). Head-to-head data on the diagnostic performance of different MPI modalities in this setting are sparse. OBJECTIVES The authors sought to compare, head-to-head, the diagnostic performance of selective MPI by 3.0-T cardiac magnetic resonance (CMR) and 82rubidium positron emission tomography (RbPET) in patients with suspected obstructive stenosis at coronary CTA using invasive coronary angiography (ICA) with fractional flow reserve (FFR) as reference. METHODS Consecutive patients (n = 1,732, mean age: 59.1 ± 9.5, 57.2% men) referred for coronary CTA with symptoms suggestive of obstructive CAD were included. Patients with suspected stenosis were referred for both CMR and RbPET and subsequently ICA. Obstructive CAD was defined as FFR ≤0.80 or >90% diameter stenosis by visual assessment. RESULTS In total, 445 patients had suspected stenosis on coronary CTA. Of these, 372 patients completed both CMR, RbPET and subsequent ICA with FFR. Hemodynamically obstructive CAD was identified in 164 of 372 (44.1%) patients. Sensitivities for CMR and RbPET were 59% (95% CI: 51%-67%) and 64% (95% CI: 56%-71%); P = 0.21, respectively, and specificities 84% (95% CI: 78%-89%) and 89% (95% CI: 84%-93%]); P = 0.08, respectively. Overall accuracy was higher for RbPET compared with CMR (73% vs 78%; P = 0.03). CONCLUSIONS In patients with suspected obstructive stenosis at coronary CTA, CMR, and RbPET show similar and moderate sensitivities but high specificities compared with ICA with FFR. This patient group represents a diagnostic challenge with frequent mismatch between advanced MPI tests and invasive measurements. (Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 2 [Dan-NICAD 2]; NCT03481712).
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Affiliation(s)
- Laust Dupont Rasmussen
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christin Isaksen
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways Silkeborg Regional Hospital, Denmark
| | - Lau Brix
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways Silkeborg Regional Hospital, Denmark; Department of Procurement and Biomedical Engineering, Region Midt, Aarhus C, Denmark
| | | | - Theodore Murphy
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom
| | - Xenios Milidonis
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | | | | | - Osama Hammid
- Department of Cardiology, Regional Hospital East Jutland, Randers, Denmark
| | - Jesper Mortensen
- Department of Nuclear Medicine, Gødstrup Hospital, Herning, Denmark
| | | | - Lars Christian Gormsen
- Department of Clinical Medicine, Aarhus University, Denmark; Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | | | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom; William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, United Kingdom
| | - Morten Böttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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12
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El Hussein MT, Fibich E. Noninvasive diagnostic modalities for the diagnosis of coronary artery disease: A guide for acute care NPs. Nurse Pract 2022; 47:27-36. [PMID: 36165970 DOI: 10.1097/01.npr.0000873524.89648.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Selecting noninvasive diagnostic tests for coronary artery disease can be a daunting task to acute care NPs. This article provides an overview of the pathophysiology of coronary artery disease, relevant noninvasive diagnostic imaging modalities, and an evidence-based approach to guide subsequent diagnostic and therapeutic interventions.
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13
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Management des chronischen Koronarsyndroms. Herz 2022; 47:472-482. [DOI: 10.1007/s00059-022-05137-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/27/2022]
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14
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Zheng C, Sun BC, Wu YL, Ferencik M, Lee MS, Redberg RF, Kawatkar AA, Musigdilok VV, Sharp AL. Automated interpretation of stress echocardiography reports using natural language processing. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:626-637. [PMID: 36710893 PMCID: PMC9779789 DOI: 10.1093/ehjdh/ztac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/08/2022] [Indexed: 02/01/2023]
Abstract
Aims Stress echocardiography (SE) findings and interpretations are commonly documented in free-text reports. Reusing SE results requires laborious manual reviews. This study aimed to develop and validate an automated method for abstracting SE reports in a large cohort. Methods and results This study included adult patients who had SE within 30 days of their emergency department visit for suspected acute coronary syndrome in a large integrated healthcare system. An automated natural language processing (NLP) algorithm was developed to abstract SE reports and classify overall SE results into normal, non-diagnostic, infarction, and ischaemia categories. Randomly selected reports (n = 140) were double-blindly reviewed by cardiologists to perform criterion validity of the NLP algorithm. Construct validity was tested on the entire cohort using abstracted SE data and additional clinical variables. The NLP algorithm abstracted 6346 consecutive SE reports. Cardiologists had good agreements on the overall SE results on the 140 reports: Kappa (0.83) and intraclass correlation coefficient (0.89). The NLP algorithm achieved 98.6% specificity and negative predictive value, 95.7% sensitivity, positive predictive value, and F-score on the overall SE results and near-perfect scores on ischaemia findings. The 30-day acute myocardial infarction or death outcomes were highest among patients with ischaemia (5.0%), followed by infarction (1.4%), non-diagnostic (0.8%), and normal (0.3%) results. We found substantial variations in the format and quality of SE reports, even within the same institution. Conclusions Natural language processing is an accurate and efficient method for abstracting unstructured SE reports. This approach creates new opportunities for research, public health measures, and care improvement.
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Affiliation(s)
- Chengyi Zheng
- Corresponding author. Tel: 1-626-376-7029, Fax: 626-564-3694,
| | - Benjamin C Sun
- Department of Emergency Medicine and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yi-Lin Wu
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA 91101, USA
| | - Maros Ferencik
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, OR 97239, USA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA 90027, USA
| | - Rita F Redberg
- Division of Cardiology, University of California, San Francisco, CA 94143, USA
| | - Aniket A Kawatkar
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA 91101, USA
| | - Visanee V Musigdilok
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA 91101, USA
| | - Adam L Sharp
- Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, 2nd Floor, Pasadena, CA 91101, USA,Clinical Science Department, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, USA
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15
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Károlyi M, Gotschy A, Polacin M, Plein S, Paetsch I, Jahnke C, Frick M, Gebker R, Alkadhi H, Kozerke S, Manka R. Diagnostic performance of 3D cardiac magnetic resonance perfusion in elderly patients for the detection of coronary artery disease as compared to fractional flow reserve. Eur Radiol 2022; 33:339-347. [PMID: 35984513 DOI: 10.1007/s00330-022-09040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/09/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In patients of advanced age, the feasibility of myocardial ischemia testing might be limited by age-related comorbidities and falling compliance abilities. Therefore, we aimed to test the accuracy of 3D cardiac magnetic resonance (CMR) stress perfusion in the elderly population as compared to reference standard fractional flow reserve (FFR). METHODS Fifty-six patients at age 75 years or older (mean age 79 ± 4 years, 35 male) underwent 3D CMR perfusion imaging and invasive coronary angiography with FFR in 5 centers using the same study protocol. The diagnostic accuracy of CMR was compared to a control group of 360 patients aged below 75 years (mean age 61 ± 9 years, 262 male). The percentage of myocardial ischemic burden (MIB) relative to myocardial scar burden was further analyzed using semi-automated software. RESULTS Sensitivity, specificity, and positive and negative predictive values of 3D perfusion CMR deemed similar for both age groups in the detection of hemodynamically relevant (FFR < 0.8) stenosis (≥ 75 years: 86%, 83%, 92%, and 75%; < 75 years: 87%, 80%, 82%, and 85%; p > 0.05 all). While MIB was larger in the elderly patients (15% ± 17% vs. 9% ± 13%), the diagnostic accuracy of 3D CMR perfusion was high in both elderly and non-elderly populations to predict pathological FFR (AUC: 0.906 and 0.866). CONCLUSIONS 3D CMR perfusion has excellent diagnostic accuracy for the detection of hemodynamically relevant coronary stenosis, independent of patient age. KEY POINTS • The increasing prevalence of coronary artery disease in elderly populations is accompanied with a larger ischemic burden of the myocardium as compared to younger individuals. • 3D cardiac magnetic resonance perfusion imaging predicts pathological fractional flow reserve in elderly patients aged ≥ 75 years with high diagnostic accuracy. • Ischemia testing with 3D CMR perfusion imaging has similarly high accuracy in the elderly as in younger patients and it might be particularly useful when other non-invasive techniques are limited by aging-related comorbidities and falling compliance abilities.
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Affiliation(s)
- Mihály Károlyi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Gotschy
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland.,Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Malgorzata Polacin
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & the Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Ingo Paetsch
- Department of Electrophysiology, HELIOS Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Cosima Jahnke
- Department of Electrophysiology, HELIOS Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Michael Frick
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Sebastian Kozerke
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Robert Manka
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland. .,Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland.
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16
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Impact of Coronary Artery Disease on the Myocardium: Importance of Ischemia, Infarction, and Contractility. JACC Cardiovasc Imaging 2022; 15:1423-1426. [PMID: 35926900 DOI: 10.1016/j.jcmg.2022.05.011] [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: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022]
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17
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Kato T, Momose M, Uemura Y, Naya M, Matsumoto N, Hida S, Yamauchi T, Nakajima T, Suzuki E, Inoko M, Tamaki N. Association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan. J Cardiol 2022; 80:475-481. [PMID: 35835641 DOI: 10.1016/j.jjcc.2022.06.012] [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: 03/14/2022] [Revised: 06/06/2022] [Accepted: 06/12/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial. We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan. METHODS From the data of 2780 patients with stable angina who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referrednon-invasive imaging tests (Japanese Coronary-Angiography or Myocardial Imaging for Angina Pectoris Study), 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1year. RESULTS Patients with ≥10% myocardial ischemia (n=173) were less likely to be women than patients with <10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (6.9% vs. 1.8%, p<0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to <10% myocardial ischemia for MACEs remained significant [adjusted hazard ratio (95% confidence interval), 2.40 (1.09-5.26), p=0.029]. After adjusting including treatments, the risk of MACEs became insignificant between the ≥10% myocardial ischemia group and the <10% myocardial ischemia group [adjusted hazard ratio (95% confidence interval), 1.04 (0.45-2.45), p=0.92]. CONCLUSION The presence of ≥10% myocardial ischemia at diagnosis was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.
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Affiliation(s)
- Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Mitsuru Momose
- Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Science, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoya Matsumoto
- Department of Cardiovascular Medicine, Nihon University, Tokyo, Japan
| | - Satoshi Hida
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Takao Yamauchi
- Cardiovascular Medicine, JCHO Sagamino Hospital, Sagamihara, Japan
| | | | - Eriko Suzuki
- Department of Nuclear Medicine, Hokkaido University, Sapporo, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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18
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Lunardi M, Louvard Y, Lefèvre T, Stankovic G, Burzotta F, Kassab GS, Lassen JF, Darremont O, Garg S, Koo BK, Holm NR, Johnson TW, Pan M, Chatzizisis YS, Banning A, Chieffo A, Dudek D, Hildick-Smith D, Garot J, Henry TD, Dangas G, Stone GW, Krucoff MW, Cutlip D, Mehran R, Wijns W, Sharif F, Serruys PW, Onuma Y. Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations. J Am Coll Cardiol 2022; 80:63-88. [PMID: 35597684 DOI: 10.1016/j.jacc.2022.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/03/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
Abstract
The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.
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Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway, Galway, Ireland; Division of Cardiology, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Yves Louvard
- Institut Cardiovasculaire Paris Sud, Massy, France
| | | | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ghassan S Kassab
- California Medical Innovation Institute, San Diego, California, USA
| | - Jens F Lassen
- Department of Cardiology B, Odense Universitets Hospital and University of Southern Denmark, Odense C, Denmark
| | | | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Thomas W Johnson
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol NHSFT & University of Bristol, Bristol, United Kingdom
| | - Manuel Pan
- IMIBIC, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Yiannis S Chatzizisis
- Cardiovascular Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Adrian Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Alaide Chieffo
- Division of Cardiology, San Raffaele Hospital, Milan, Italy
| | - Dariusz Dudek
- Second Department of Cardiology Jagiellonian University Medical College, Krakow, Poland
| | | | - Jérome Garot
- Institut Cardiovasculaire Paris Sud, Massy, France
| | - Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, Ohio, USA
| | - George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mitchell W Krucoff
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Baim Institute for Clinical Research and Harvard Medical School, Boston, Massachusetts, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Wijns
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway, Galway, Ireland; The Lambe Institute for Translational Medicine and CURAM, National University of Ireland Galway, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway, Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway, Galway, Ireland; International Centre for Circulatory Health, NHLI, Imperial College, London, United Kingdom.
| | - Yoshinobu Onuma
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway, Galway, Ireland
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19
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Lee SH, Shin D, Lee JM, van de Hoef TP, Hong D, Choi KH, Hwang D, Boerhout CKM, de Waard GA, Jung JH, Mejia-Renteria H, Hoshino M, Echavarria-Pinto M, Meuwissen M, Matsuo H, Madera-Cambero M, Eftekhari A, Effat MA, Murai T, Marques K, Doh JH, Christiansen EH, Banerjee R, Kim HK, Nam CW, Niccoli G, Nakayama M, Tanaka N, Shin ES, Chamuleau SAJ, van Royen N, Knaapen P, Koo BK, Kakuta T, Escaned J, Piek JJ. Clinical Relevance of Ischemia with Nonobstructive Coronary Arteries According to Coronary Microvascular Dysfunction. J Am Heart Assoc 2022; 11:e025171. [PMID: 35475358 PMCID: PMC9238617 DOI: 10.1161/jaha.121.025171] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background In the absence of obstructive coronary stenoses, abnormality of noninvasive stress tests (NIT) in patients with chronic coronary syndromes may indicate myocardial ischemia of nonobstructive coronary arteries (INOCA). The differential prognosis of INOCA according to the presence of coronary microvascular dysfunction (CMD) and incremental prognostic value of CMD with intracoronary physiologic assessment on top of NIT information remains unknown. Methods and Results From the international multicenter registry of intracoronary physiologic assessment (ILIAS [Inclusive Invasive Physiological Assessment in Angina Syndromes] registry, N=2322), stable patients with NIT and nonobstructive coronary stenoses with fractional flow reserve >0.80 were selected. INOCA was diagnosed when patients showed positive NIT results. CMD was defined as coronary flow reserve ≤2.5. According to the presence of INOCA and CMD, patients were classified into 4 groups: group 1 (no INOCA nor CMD, n=116); group 2 (only CMD, n=90); group 3 (only INOCA, n=41); and group 4 (both INOCA and CMD, n=40). The primary outcome was major adverse cardiovascular events, a composite of all‐cause death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 5 years. Among 287 patients with nonobstructive coronary stenoses (fractional flow reserve=0.91±0.06), 81 patients (38.2%) were diagnosed with INOCA based on positive NIT. By intracoronary physiologic assessment, 130 patients (45.3%) had CMD. Regardless of the presence of INOCA, patients with CMD showed a significantly lower coronary flow reserve and higher hyperemic microvascular resistance compared with patients without CMD (P<0.001 for all). The cumulative incidence of major adverse cardiovascular events at 5 years were 7.4%, 21.3%, 7.7%, and 34.4% in groups 1 to 4. By documenting CMD (groups 2 and 4), intracoronary physiologic assessment identified patients at a significantly higher risk of major adverse cardiovascular events at 5 years compared with group 1 (group 2: adjusted hazard ratio [HRadjusted], 2.88; 95% CI, 1.52–7.19; P=0.024; group 4: HRadjusted, 4.00; 95% CI, 1.41–11.35; P=0.009). Conclusions In stable patients with nonobstructive coronary stenoses, a diagnosis of INOCA based only on abnormal NIT did not identify patients with higher risk of long‐term cardiovascular events. Incorporating intracoronary physiologic assessment to NIT information in patients with nonobstructive disease allowed identification of patient subgroups with up to 4‐fold difference in long‐term cardiovascular events. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04485234.
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology Department of Internal Medicine Chonnam National University HospitalChonnam National University Medical School Gwangju Korea
| | - Doosup Shin
- Division of Cardiovascular Medicine Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Joo Myung Lee
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Tim P van de Hoef
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands.,Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands.,Department of Cardiology NoordWest Ziekenhuisgroep The Netherlands
| | - David Hong
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Ki Hong Choi
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Doyeon Hwang
- Department of Internal Medicine Cardiovascular CenterSeoul National University Hospital Seoul Korea
| | - Coen K M Boerhout
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands
| | - Guus A de Waard
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Ji-Hyun Jung
- Sejong General HospitalSejong Heart Institute Bucheon Korea
| | - Hernan Mejia-Renteria
- Hospital Clínico San CarlosIDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Masahiro Hoshino
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura City Japan
| | - Mauro Echavarria-Pinto
- Hospital General ISSSTE Querétaro - Facultad de MedicinaUniversidad Autónoma de Querétaro Querétaro México
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan
| | | | - Ashkan Eftekhari
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | - Mohamed A Effat
- Division of Cardiovascular Health and Disease University of Cincinnati Cincinnati Ohio
| | - Tadashi Murai
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura City Japan
| | - Koen Marques
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Joon-Hyung Doh
- Department of Medicine Inje University Ilsan Paik Hospital Goyang Korea
| | | | - Rupak Banerjee
- Department of Mechanical and Materials Engineering University of CincinnatiVeterans Affairs Medical Center Cincinnati Ohio
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center Chosun University HospitalUniversity of Chosun College of Medicine Gwangju Korea
| | - Chang-Wook Nam
- Department of Medicine Keimyung University Dongsan Medical Center Daegu Korea
| | | | - Masafumi Nakayama
- Department of Cardiovascular Medicine Gifu Heart Center Gifu Japan.,Toda Central General HospitalCardiovascular Center Toda Japan
| | - Nobuhiro Tanaka
- Department of Cardiology Tokyo Medical University Hachioji Medical Center Tokyo Japan
| | - Eun-Seok Shin
- Department of Cardiology Ulsan University HospitalUniversity of Ulsan College of Medicine Ulsan Korea
| | - Steven A J Chamuleau
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands.,Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Niels van Royen
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands
| | - Paul Knaapen
- Department of Cardiology Amsterdam UMC - location VUmc Amsterdam The Netherlands
| | - Bon Kwon Koo
- Department of Internal Medicine Cardiovascular CenterSeoul National University Hospital Seoul Korea
| | - Tsunekazu Kakuta
- Department of Cardiology Tsuchiura Kyodo General Hospital Tsuchiura City Japan
| | - Javier Escaned
- Hospital Clínico San CarlosIDISSC, and Universidad Complutense de Madrid Madrid Spain
| | - Jan J Piek
- Department of Cardiology Amsterdam UMC - location AMC Amsterdam The Netherlands
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20
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Ties D, van Dorp P, Pundziute G, van der Aalst CM, Gratama JWC, Braam RL, Kuijpers D, Lubbers DD, van der Bilt IA, Westenbrink BD, Wolcherink MJO, Doggen CJ, Išgum I, Nijveldt R, de Koning HJ, Vliegenthart R, Oudkerk M, van der Harst P. Early detection of obstructive coronary artery disease in the asymptomatic high-risk population: objectives and study design of the EARLY-SYNERGY trial. Am Heart J 2022; 246:166-177. [PMID: 35038412 DOI: 10.1016/j.ahj.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/11/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) burden for society is expected to steeply increase over the next decade. Improved feasibility and efficiency of preventive strategies is necessary to flatten the curve. Acute myocardial infarction (AMI) is the main determinant of CAD-related mortality and morbidity, and predominantly occurs in individuals with more advanced stages of CAD causing subclinical myocardial ischemia (obstructive CAD; OCAD). Unfortunately, OCAD can remain subclinical until its destructive presentation with AMI or sudden death. Current primary preventive strategies are not designed to differentiate between non-OCAD and OCAD and the opportunity is missed to treat individuals with OCAD more aggressively. METHODS EARLY-SYNERGY is a multicenter, randomized-controlled clinical trial in individuals with coronary artery calcium (CAC) presence to study (1.) the yield of cardiac magnetic resonance stress myocardial perfusion imaging (CMR-MPI) for early OCAD diagnosis and (2) whether early OCAD diagnosis improves outcomes. Individuals with CAC score ≥300 objectified in 2 population-based trials (ROBINSCA; ImaLife) are recruited for study participation. Eligible candidates are randomized 1:1 to cardiac magnetic resonance stress myocardial perfusion imaging (CMR-MPI) or no additional functional imaging. In the CMR-MPI arm, feedback on imaging results is provided to primary care provider and participant in case of guideline-based actionable findings. Participants are followed-up for clinical events, healthcare utilization and quality of life. CONCLUSIONS EARLY-SYNERGY is the first randomized-controlled clinical trial designed to test the hypothesis that subclinical OCAD is widely present in the general at-risk population and that early differentiation of OCAD from non-OCAD followed by guideline-recommended treatment improves outcomes.
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21
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Nakano S, Kohsaka S, Chikamori T, Fukushima K, Kobayashi Y, Kozuma K, Manabe S, Matsuo H, Nakamura M, Ohno T, Sawano M, Toda K, Ueda Y, Yokoi H, Gatate Y, Kasai T, Kawase Y, Matsumoto N, Mori H, Nakazato R, Niimi N, Saito Y, Shintani A, Watanabe I, Watanabe Y, Ikari Y, Jinzaki M, Kosuge M, Nakajima K, Kimura T. JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease. Circ J 2022; 86:882-915. [DOI: 10.1253/circj.cj-21-1041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shintaro Nakano
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Kenji Fukushima
- Department of Radiology and Nuclear Medicine, Fukushima Medical University
| | | | - Ken Kozuma
- Cardiology, Teikyo University School of Medicine
| | - Susumu Manabe
- Cardiac Surgery, International University of Health and Welfare Mita Hospital
| | | | - Masato Nakamura
- Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | | | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | - Hiroyoshi Yokoi
- Cardiovascular Center, International University of Health and Welfare Fukuoka Sanno Hospital
| | - Yodo Gatate
- Cardiology, Self-Defense Forces Central Hospital
| | | | | | | | - Hitoshi Mori
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Yuichi Saito
- Cardiovascular Medicine, Chiba University School of Medicine
| | - Ayumi Shintani
- Medical Statistics, Osaka City University Graduate School of Medicine
| | - Ippei Watanabe
- Cardiovascular Medicine, Toho University School of Medicine
| | | | - Yuji Ikari
- Cardiology, Tokai University School of Medicine
| | | | | | - Kenichi Nakajima
- Functional Imaging and Artificial Intelligence, Kanazawa University
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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22
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Bertolone DT, Gallinoro E, Esposito G, Paolisso P, Bermpeis K, De Colle C, Fabbricatore D, Mileva N, Valeriano C, Munhoz D, Belmonte M, Vanderheyden M, Bartunek J, Sonck J, Wyffels E, Collet C, Mancusi C, Morisco C, De Luca N, De Bruyne B, Barbato E. Contemporary Management of Stable Coronary Artery Disease. High Blood Press Cardiovasc Prev 2022; 29:207-219. [PMID: 35147890 PMCID: PMC9050764 DOI: 10.1007/s40292-021-00497-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/30/2021] [Indexed: 10/28/2022] Open
Abstract
Coronary artery disease (CAD) continues to be the leading cause of mortality and morbidity in developed countries. Assessment of pre-test probability (PTP) based on patient's characteristics, gender and symptoms, help to identify more accurate patient's clinical likelihood of coronary artery disease. Consequently, non-invasive imaging tests are performed more appropriately to rule in or rule out CAD rather than invasive coronary angiography (ICA). Coronary computed tomography angiography (CCTA) is the first-line non-invasive imaging technique in patients with suspected CAD and could be used to plan and guide coronary intervention. Invasive coronary angiography remains the gold-standard method for the identification and characterization of coronary artery stenosis. However, it is recommended in patients where the imaging tests are non-conclusive, and the clinical likelihood is very high, remembering that in clinical practice, approximately 30 to 70% of patients with symptoms and/or signs of ischemia, referred to coronary angiography, have non obstructive coronary artery disease (INOCA). In this contest, physiology and imaging-guided revascularization represent the cornerstone of contemporary management of chronic coronary syndromes (CCS) patients allowing us to focus specifically on ischemia-inducing stenoses. Finally, we also discuss contemporary medical therapeutic approach for secondary prevention. The aim of this review is to provide an updated diagnostic and therapeutic approach for the management of patients with stable coronary artery disease.
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Affiliation(s)
- Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Esposito
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Cristina De Colle
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Davide Fabbricatore
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Niya Mileva
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | | | - Daniel Munhoz
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | | | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Eric Wyffels
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Costantino Mancusi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Carmine Morisco
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Nicola De Luca
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium.,Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Emanuele Barbato
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium. .,Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
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23
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Yong J, Tian J, Zhao X, Yang X, Zhang M, Zhou Y, He Y, Song X. Revascularization or medical therapy for stable coronary artery disease patients with different degrees of ischemia: a systematic review and meta-analysis of the role of myocardial perfusion. Ther Adv Chronic Dis 2022; 13:20406223211056713. [PMID: 35070247 PMCID: PMC8777334 DOI: 10.1177/20406223211056713] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/30/2021] [Indexed: 01/09/2023] Open
Abstract
Objective: This study explored the best treatment strategies for stable coronary artery disease (SCAD) patients with differing levels of ischemic severity. Methods: We conducted a comprehensive search of the PubMed, EMBASE, and Cochrane databases – searching for relevant articles through 4 February 2021. We selected studies comparing different treatments for patients with SCAD who had received ischemia assessments. The primary outcome was death. The secondary outcomes were major adverse cardiovascular events (MACEs) and myocardial infarction (MI). Results: A total of 11 studies, including 35,607 subjects, were selected for this meta-analysis. Results showed that, compared with medical therapy, revascularization could reduce MACE incidence (odds ratio (OR) 0.73, 95% confidence interval (CI): 0.57–0.94, p < 0.05) in SCAD patients with myocardial ischemia, but that it was not effective for patients without ischemia. For mild ischemia, the incidence of death (OR 0.78, 95% CI: 0.59–1.01, p = 0.063), MACE (OR 0.91, 95% CI: 0.48–1.70, p = 0.762), or MI (OR 1.44, 95% CI: 0.94–2.19, p = 0.093) was the same whether they were treated with revascularization or medical therapy. For moderate to severe ischemia, revascularization reduced the incidence of MACE (OR 0.59, 95% CI: 0.42–0.83, p < 0.05) and MI (OR 0.83, 95% CI: 0.71–0.98, p < 0.05), but the incidence of death (OR 0.73, 95% CI: 0.47–1.12, p = .145) was similar. For SCAD patients with severe ischemia, revascularization may confer survival benefits (OR 0.46, 95% CI: 0.21–1.00, p = 0.05). Conclusion: For SCAD patients with moderate to severe ischemia, revascularization reduces the MACE and MI incidences, but does not change the incidence of death. Evaluation for myocardial ischemia is vital when selecting a therapeutic strategy.
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Affiliation(s)
- JingWen Yong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - JinFan Tian
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - XueYao Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - MingDuo Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Yongan Road 95, Beijing 100050, China
| | - XianTao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road No. 2, Chaoyang District, Beijing 100029, China
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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25
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Sheiban I, Figini F, Gasparetto V, D’Ascenzo F, Moretti C, Leonardo F. Side Branch is the Main Determinant Factor of Bifurcation Lesion Complexity: Critical Review with a Proposal Based on Single-centre Experience. Heart Int 2021; 15:67-72. [PMID: 36277829 PMCID: PMC9524656 DOI: 10.17925/hi.2021.15.2.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/08/2021] [Indexed: 10/25/2023] Open
Abstract
Although bifurcation stenting can be often managed with a simple provisional approach, in some settings, more complex techniques are appropriate. Based on our clinical experience and on data from literature, we propose a simple algorithm that may assist in selecting cases for elective double stenting. We found that, when the side branch is of adequate dimensions and affected by significant disease (longer than 10 mm and/or with presence of ostial calcifications), double stenting is associated with a lower incidence of adverse events, compared with provisional stenting.
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Affiliation(s)
- Imad Sheiban
- Ospedale “Pederzoli”, Peschiera del Garda, Italy
| | | | | | - Fabrizio D’Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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26
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Assante R, Zampella E, Acampa W. Advanced technology in the risk stratification-based strategy: The way forward to keep going. J Nucl Cardiol 2021; 28:2937-2940. [PMID: 32533425 DOI: 10.1007/s12350-020-02198-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy.
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27
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 310] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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28
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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29
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Franks R, Holtackers RJ, Alskaf E, Nazir MS, Clapp B, Wildberger JE, Perera D, Plein S, Chiribiri A. The impact of dark-blood versus conventional bright-blood late gadolinium enhancement on the myocardial ischemic burden. Eur J Radiol 2021; 144:109947. [PMID: 34700091 DOI: 10.1016/j.ejrad.2021.109947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE In perfusion cardiovascular magnetic resonance (CMR), ischemic burden predicts adverse prognosis and is often used to guide revascularization. Ischemic scar tissue can cause stress perfusion defects that do not represent myocardial ischemia. Dark-blood late gadolinium enhancement (LGE) methods detect more scar than conventional bright-blood LGE, however, the impact on the myocardial ischemic burden estimation is unknown and evaluated in this study. METHODS Forty patients with CMR stress perfusion defects and ischemic scar on both dark-blood and bright-blood LGE were included. For dark-blood LGE, phase sensitive inversion recovery imaging with left ventricular blood pool nulling was used. Ischemic scar burden was quantified for both methods using >5 standard deviations above remote myocardium. Perfusion defects were manually contoured, and the myocardial ischemic burden was calculated by subtracting the ischemic scar burden from the perfusion defect burden. RESULTS Ischemic scar burden by dark-blood LGE was higher than bright-blood LGE (13.3 ± 7.4% vs. 10.3 ± 7.1%, p < 0.001). Dark-blood LGE derived myocardial ischemic burden was lower compared with bright-blood LGE (15.6% (IQR: 10.3 to 22.0) vs. 19.3 (10.9 to 25.5), median difference -2.0%, p < 0.001) with a mean bias of -2.8% (95% confidence intervals: -4.0 to -1.6%) and a large effect size (r = 0.62). CONCLUSION Stress perfusion defects are associated with higher ischemic scar burden using dark-blood LGE compared with bright-blood LGE, which leads to a lower estimation of the myocardial ischemic burden. The prognostic value of using a dark-blood LGE derived ischemic burden to guide revascularization is unknown and warrants further investigation.
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Affiliation(s)
- Russell Franks
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom.
| | - Robert J Holtackers
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.
| | - Ebraham Alskaf
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom.
| | - Muhummad Sohaib Nazir
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom.
| | - Brian Clapp
- Cardiovascular Division, King's College London, London, United Kingdom.
| | - Joachim E Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Radiology & Nuclear Medicine, Maastricht University Medical Centre, Maastricht, Netherlands.
| | - Divaka Perera
- Cardiovascular Division, King's College London, London, United Kingdom.
| | - Sven Plein
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
| | - Amedeo Chiribiri
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom.
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30
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Franks R, Plein S, Chiribiri A. Clinical Application of Dynamic Contrast Enhanced Perfusion Imaging by Cardiovascular Magnetic Resonance. Front Cardiovasc Med 2021; 8:768563. [PMID: 34778420 PMCID: PMC8585782 DOI: 10.3389/fcvm.2021.768563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022] Open
Abstract
Functionally significant coronary artery disease impairs myocardial blood flow and can be detected non-invasively by myocardial perfusion imaging. While multiple myocardial perfusion imaging modalities exist, the high spatial and temporal resolution of cardiovascular magnetic resonance (CMR), combined with its freedom from ionising radiation make it an attractive option. Dynamic contrast enhanced CMR perfusion imaging has become a well-validated non-invasive tool for the assessment and risk stratification of patients with coronary artery disease and is recommended by international guidelines. This article presents an overview of CMR perfusion imaging and its clinical application, with a focus on chronic coronary syndromes, highlighting its strengths and challenges, and discusses recent advances, including the emerging role of quantitative perfusion analysis.
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Affiliation(s)
- Russell Franks
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Sven Plein
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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31
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Dettori R, Frick M, Burgmaier K, Lubberich RK, Hellmich M, Marx N, Reith S, Burgmaier M, Milzi A. Quantitative Flow Ratio Is Associated with Extent and Severity of Ischemia in Non-Culprit Lesions of Patients with Myocardial Infarction. J Clin Med 2021; 10:jcm10194535. [PMID: 34640551 PMCID: PMC8509261 DOI: 10.3390/jcm10194535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022] Open
Abstract
Quantitative flow ratio (QFR) is a novel method to assess the relevance of coronary stenoses based only on angiographic projections. We could previously show that QFR is able to predict the hemodynamic relevance of non-culprit lesions in patients with myocardial infarction. However, it is still unclear whether QFR is also associated with the extent and severity of ischemia, which can effectively be assessed with imaging modalities such as cardiac magnetic resonance (CMR). Thus, our aim was to evaluate the associations of QFR with both extent and severity of ischemia. We retrospectively determined QFR in 182 non-culprit coronary lesions from 145 patients with previous myocardial infarction, and compared it with parameters assessing extent and severity of myocardial ischemia in staged CMR. Whereas ischemic burden in lesions with QFR > 0.80 was low (1.3 ± 5.5% in lesions with QFR ≥ 0.90; 1.8 ± 7.3% in lesions with QFR 0.81–0.89), there was a significant increase in ischemic burden in lesions with QFR ≤ 0.80 (16.6 ± 15.6%; p < 0.001 for QFR ≥ 0.90 vs. QFR ≤ 0.80). These data could be confirmed by other parameters assessing extent of ischemia. In addition, QFR was also associated with severity of ischemia, assessed by the relative signal intensity of ischemic areas. Finally, QFR predicts a clinically relevant ischemic burden ≥ 10% with good diagnostic accuracy (AUC 0.779, 95%-CI: 0.666–0.892, p < 0.001). QFR may be a feasible tool to identify not only the presence, but also extent and severity of myocardial ischemia in non-culprit lesions of patients with myocardial infarction.
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Affiliation(s)
- Rosalia Dettori
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Michael Frick
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Kathrin Burgmaier
- Department of Pediatrics, University Hospital Cologne, D-50937 Cologne, Germany;
| | - Richard Karl Lubberich
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine and University Hospital Cologne, University of Cologne, D-50937 Cologne, Germany;
| | - Nikolaus Marx
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Sebastian Reith
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Mathias Burgmaier
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
| | - Andrea Milzi
- Department of Cardiology, University Hospital of the RWTH Aachen, D-52070 Aachen, Germany; (R.D.); (M.F.); (R.K.L.); (N.M.); (S.R.); (M.B.)
- Correspondence:
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32
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van Diemen PA, Wijmenga JT, Driessen RS, Bom MJ, Schumacher SP, Stuijfzand WJ, Everaars H, de Winter RW, Raijmakers PG, van de Ven PM, van Rossum AC, Danad I, Knaapen P. Defining the prognostic value of [15O]H2O positron emission tomography-derived myocardial ischaemic burden. Eur Heart J Cardiovasc Imaging 2021; 22:638-646. [PMID: 33200201 DOI: 10.1093/ehjci/jeaa305] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/23/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Myocardial ischaemic burden (IB) is used for the risk stratification of patients with coronary artery disease (CAD). This study sought to define a prognostic threshold for quantitative [15O]H2O positron emission tomography (PET)-derived IB. METHODS AND RESULTS A total of 623 patients with suspected or known CAD who underwent [15O]H2O PET perfusion imaging were included. The endpoint was a composite of death and non-fatal myocardial infarction (MI). A hyperaemic myocardial blood flow (hMBF) and myocardial flow reserve (MFR)-derived IB were determined. During a median follow-up time of 6.7 years, 62 patients experienced an endpoint. A hMBF IB of 24% and MFR IB of 28% were identified as prognostic thresholds. Patients with a high hMBF or MFR IB (above threshold) had worse outcome compared to patients with a low hMBF IB [annualized event rates (AER): 2.8% vs. 0.6%, P < 0.001] or low MFR IB [AER: 2.4% vs. 0.6%, P < 0.001]. Patients with a concordant high IB had the worst outcome (AER: 3.1%), whereas patients with a concordant low or discordant IB result had similar and low AERs of 0.5% and 0.9% (P = 0.953), respectively. Both thresholds were of prognostic value beyond clinical characteristics, however, only the hMBF IB threshold remained predictive when adjusted for clinical characteristics and combined use of the hMBF and MFR thresholds. CONCLUSION A hMBF IB ≥24% was a stronger predictor of adverse outcome than an MFR IB ≥28%. Nevertheless, classifying patients according to concordance of IB result allowed for the identification of low- and high-risk patients.
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Affiliation(s)
- Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jan-Thijs Wijmenga
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Roel S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Michiel J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wynand J Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Henk Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine & PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Lesion Geometry as Assessed by Optical Coherence Tomography Is Related to Myocardial Ischemia as Determined by Cardiac Magnetic Resonance Imaging. J Clin Med 2021; 10:jcm10153342. [PMID: 34362126 PMCID: PMC8348708 DOI: 10.3390/jcm10153342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Although the relationship between the geometry of coronary stenosis and the presence of myocardial ischemia is well known, the association between stenosis geometry and severity and/or extent of ischemia is still unexplored. Thus, we investigated this relationship using optical coherence tomography (OCT) to assess stenosis parameters and cardiac magnetic resonance imaging (CMR) to determine both extent and severity of ischemia. METHODS We analyzed 55 lesions from 51 patients with stable angina. Pre-interventionally, all patients underwent OCT-analysis of stenosis morphology as well as CMR to determine both the extent and severity of myocardial ischemia. RESULTS Percent area stenosis (%AS) was significantly associated with ischemic burden (r = 0.416, p = 0.003). Similar results could be obtained for other stenosis parameters as well as for several other parameters assessing the extent of ischemia. Furthermore, OCT-derived stenosis parameters were associated with the product of ischemic burden and severity of ischemia (%AS: r = 0.435, p = 0.002; similar results for other parameters). A Poiseuille's-law-modelled combination of stenosis length and minimal lumen diameter yielded a good diagnostic efficiency (AUC 0.787) in predicting an ischemic burden >10%. CONCLUSIONS Our data highlight the key role of the geometry of coronary lesions in determining myocardial ischemia.
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34
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Neglia D, Liga R, Caselli C, Carpeggiani C, Lorenzoni V, Sicari R, Lombardi M, Gaemperli O, Kaufmann PA, Scholte AJHA, Underwood SR, Knuuti J. Anatomical and functional coronary imaging to predict long-term outcome in patients with suspected coronary artery disease: the EVINCI-outcome study. Eur Heart J Cardiovasc Imaging 2021; 21:1273-1282. [PMID: 31701136 DOI: 10.1093/ehjci/jez248] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/06/2019] [Accepted: 10/25/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS To investigate the prognostic relevance of coronary anatomy, coronary function, and early revascularization in patients with stable coronary artery disease (CAD). METHODS AND RESULTS From March 2009 to June 2012, 430 patients with suspected CAD (61 ± 9 years, 62% men) underwent coronary anatomical imaging by computed tomography coronary angiography (CTCA) and coronary functional imaging followed by invasive coronary angiography (ICA) if at least one non-invasive test was abnormal. Obstructive CAD was documented by ICA in 119 patients and 90 were revascularized within 90 days of enrolment. Core laboratory analysis showed that 134 patients had obstructive CAD by CTCA (>50% stenosis in major coronary vessels) and 79 significant ischaemia by functional imaging [>10% left ventricular (LV) myocardium]. Over mean follow-up of 4.4 years, major adverse events (AEs) (all-cause death, non-fatal myocardial infarction, or hospital admission for unstable angina or heart failure) or AEs plus late revascularization (LR) occurred in 40 (9.3%) and 58 (13.5%) patients, respectively. Obstructive CAD at CTCA was the only independent imaging predictor of AEs [hazard ratio (HR) 3.2, 95% confidence interval (CI) 1.10-9.30; P = 0.033] and AEs plus LR (HR 4.3, 95% CI 1.56-11.81; P = 0.005). Patients with CAD in whom early revascularization was performed in the presence of ischaemia and deferred in its absence had fewer AEs, similar to patients without CAD (HR 2.0, 95% CI 0.71-5.51; P = 0.195). CONCLUSION Obstructive CAD imaged by CTCA is an independent predictor of clinical outcome. Early management of CAD targeted to the combined anatomical and functional disease phenotype improves clinical outcome.
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Affiliation(s)
- Danilo Neglia
- Cardiovascular Department, Fondazione Toscana G. Monasterio, Via G. Moruzzi 1, 56124 Pisa, Italy.,CNR, Institute of Clinical Physiology, Via G. Moruzzi 1, 56124 Pisa, Italy.,Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Riccardo Liga
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Via Roma, 67, 56126 Pisa, Italy
| | - Chiara Caselli
- CNR, Institute of Clinical Physiology, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Clara Carpeggiani
- CNR, Institute of Clinical Physiology, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Valentina Lorenzoni
- Sant'Anna School of Advanced Studies, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Rosa Sicari
- CNR, Institute of Clinical Physiology, Via G. Moruzzi 1, 56124 Pisa, Italy
| | - Massimo Lombardi
- Multimodality Cardiac Imaging Section, I.R.C.C.S. Policlinico San Donato, Piazza Edmondo Malan, 2, 20097 San Donato Milanese, Milano, Italy
| | - Oliver Gaemperli
- Cardiology, HeartClinic Hirslanden, Witellikerstrasse 40, 8032, Zürich, Switzerland
| | - Philipp A Kaufmann
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Arthur J H A Scholte
- Department of Cardiology, Heart Lung Center, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - S Richard Underwood
- Department of Non-Invasive Cardiac Imaging, Royal Brompton Hospital and Harefield Hospital, 250 King's Rd, Chelsea, London SW3 5UE, UK
| | - Juhani Knuuti
- PET Center, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
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Abstract
IMPORTANCE Nearly 10 million US adults experience stable angina, which occurs when myocardial oxygen supply does not meet demand, resulting in myocardial ischemia. Stable angina is associated with an average annual risk of 3% to 4% for myocardial infarction or death. Diagnostic tests and medical therapies for stable angina have evolved over the last decade with a better understanding of the optimal use of coronary revascularization. OBSERVATIONS Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina due to higher sensitivity and comparable specificity compared with imaging-based stress testing. Moreover, coronary computed tomographic angiography allows detection of nonobstructive atherosclerosis that would not be identified with other noninvasive imaging modalities, improving risk assessment and potentially triggering more appropriate allocation of preventive therapies. Novel therapies treating lipids (proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl) and type 2 diabetes (sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists) have improved cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care. Randomized clinical trials showed no improvement in the rates of mortality or myocardial infarction with revascularization (largely by percutaneous coronary intervention) compared with optimal medical therapy alone, even in the setting of moderate to severe ischemia. In contrast, revascularization provides a meaningful benefit on angina and quality of life compared with antianginal therapies. Measures of the effect of angina on a patient's quality of life should be integrated into the clinic encounter to assist with the decision to proceed with revascularization. CONCLUSIONS AND RELEVANCE For patients with stable angina, emphasis should be placed on optimizing lifestyle factors and preventive medications such as lipid-lowering and antiplatelet agents to reduce the risk for cardiovascular events and death. Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, should be initiated to improve angina symptoms. Revascularization with percutaneous coronary intervention should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy. Shared decision-making with an informed patient is important for effective treatment of stable angina.
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Affiliation(s)
- Parag H Joshi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - James A de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Ochs MM, Kajzar I, Salatzki J, Ochs AT, Riffel J, Osman N, Katus HA, Friedrich MG. Hyperventilation/Breath-Hold Maneuver to Detect Myocardial Ischemia by Strain-Encoded CMR: Diagnostic Accuracy of a Needle-Free Stress Protocol. JACC Cardiovasc Imaging 2021; 14:1932-1944. [PMID: 33865775 DOI: 10.1016/j.jcmg.2021.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/04/2021] [Accepted: 02/18/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the diagnostic accuracy of a fast, needle-free test for myocardial ischemia using fast Strain-ENCoded (fSENC) cardiovascular MR (CMR) after a hyperventilation/breath-hold maneuver (HVBH). BACKGROUND Myocardial stress testing is one of the most frequent diagnostic tests performed. Recent data indicate that CMR first-pass perfusion outperforms other modalities. Its use, however, is limited by the need for both, a vasodilatory stress and the intravenous application of gadolinium. Both are associated with added cost, safety concerns, and patient inconvenience. The combination of 2 novel CMR approaches, fSENC, an ultrafast technique to visualize myocardial strain, and HVBH, a physiological vasodilator, may overcome these limitations. METHODS Patients referred for CMR stress testing underwent an extended protocol to evaluate 3 different tests: 1) adenosine-perfusion; 2) adenosine-strain; and 3) HVBH-strain. Diagnostic accuracy was assessed using quantitative coronary angiography as reference. RESULTS A total of 122 patients (age 66 ± 11years; 80% men) suspected of obstructive coronary artery disease were enrolled. All participants completed the protocol without significant adverse events. Adenosine-strain and HVBH-strain provided significantly better diagnostic accuracy than adenosine-perfusion, both on a patient level (adenosine-strain: sensitivity 82%, specificity 83%; HVBH-strain: sensitivity 81%, specificity 86% vs. adenosine-perfusion: sensitivity 67%, specificity 92%; p < 0.05) and territory level (adenosine-strain: sensitivity 67%, specificity 93%; HVBH-strain: sensitivity 63%, specificity 95% vs. adenosine-perfusion: sensitivity 49%, specificity 96%; p < 0.05). However, these differences in diagnostic accuracy disappear by excluding patients with history of coronary artery bypass graft or previous myocardial infarction. The response of longitudinal strain differs significantly between ischemic and nonischemic segments to adenosine (ΔLSischemic = 0.6 ± 5.4%, ΔLSnonischemic = -0.9 ± 2.7%; p < 0.05) and HVBH (ΔLSischemic = 1.3% ± 3.8%, ΔLSnonischemic = -0.3 ± 1.8%; p = 0.002). Test duration of HVBH-strain (t = 64 ± 2 s) was significantly shorter compared with adenosine-strain (t = 184 ± 59 s; p < 0.0001) and adenosine-perfusion (t = adenosine-perfusion: 172 ± 59 s; p < 0.0001). CONCLUSIONS HVBH-strain has a high diagnostic accuracy in detecting significant coronary artery stenosis. It is not only significantly faster than any other method but also neither requires contrast agents nor pharmacological stressors.
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Affiliation(s)
- Marco M Ochs
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany.
| | - Isabelle Kajzar
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany
| | - Janek Salatzki
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany
| | - Andreas T Ochs
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany
| | - Johannes Riffel
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany
| | - Nael Osman
- MyocardialSolutions, Morrisville, North Carolina, USA
| | - Hugo A Katus
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany
| | - Matthias G Friedrich
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg, Germany; Departments of Medicine and Diagnostic Radiology, McGill University Health Centre, Montreal, Quebec, Canada
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WITHDRAWN: The impact of dark-blood versus conventional bright-blood late gadolinium enhancement on the myocardial ischemic burden. Eur J Radiol 2021. [DOI: 10.1016/j.ejrad.2021.109728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Advances in cardiac imaging: Mind the (Translational) gap. Trends Cardiovasc Med 2021; 32:124-125. [PMID: 33610723 DOI: 10.1016/j.tcm.2021.02.005] [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: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 11/21/2022]
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Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome. J Clin Med 2021; 10:jcm10040610. [PMID: 33562869 PMCID: PMC7914537 DOI: 10.3390/jcm10040610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 01/09/2023] Open
Abstract
Ischemic heart disease (IHD) persists as the leading cause of death in the Western world. In recent decades, great headway has been made in reducing mortality due to IHD, based around secondary prevention. The advent of coronary revascularization techniques, first coronary artery bypass grafting (CABG) surgery in the 1960s and then percutaneous coronary intervention (PCI) in the 1970s, has represented one of the major breakthroughs in medicine during the last century. The benefit provided by these techniques, especially PCI, has been crucial in lowering mortality rates in acute coronary syndrome (ACS). However, in the setting where IHD is most prevalent, namely chronic coronary syndrome (CCS), the increase in life expectancy provided by coronary revascularization is controversial. Over more than 40 years, several clinical trials have been carried out comparing optimal medical treatment (OMT) alone with a strategy of routine coronary revascularization on top of OMT. Beyond a certain degree of symptomatic improvement and lower incidence of minor events, routine invasive management has not demonstrated a convincing effect in terms of reducing mortality in CCS. Based on the accumulated evidence more than half a century after the first revascularization procedures were used, invasive management should be considered in those patients with uncontrolled symptoms despite OMT or high-risk features related to left ventricular function, coronary anatomy, or functional assessment, taking into account the patient expectations and preferences.
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Gibbons RJ. Myocardial Ischemia in the Management of Chronic Coronary Artery Disease: Past and Present. Circ Cardiovasc Imaging 2021; 14:e011615. [PMID: 33455408 DOI: 10.1161/circimaging.120.011615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
For many years, stress-induced myocardial ischemia has been considered important in the management of chronic coronary artery disease. Early evidence focused on the exercise ECG and the Duke treadmill score. In the 1970s, randomized clinical trials, which compared coronary artery bypass surgery to medical therapy, enrolled patients who were very different from contemporary practice and had inconsistent results. Surgery appeared to be of greatest benefit in high-risk patients defined by anatomy (such as left main disease) or stress-induced ischemia. However, randomized clinical trials of revascularization versus contemporary medical therapy over the past 20 years have been surprisingly negative. Nuclear cardiology substudies from these trials reported inconsistent results. Two observational studies from a single-center provided the best evidence for the use of stress-induced ischemia to identify patients who were most likely to benefit from revascularization. The recently completed ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) was designed to test the hypothesis that revascularization would improve outcomes in patients with moderate-severe ischemia on stress testing. Unfortunately, 14.2% of the randomized patients had either mild or no ischemia on core lab review. Nearly one-quarter of the patients were randomized on the basis of an exercise ECG without imaging. The negative results of the trial reflect the long-term population decline in coronary artery disease and abnormal stress tests, as well as improvements in patient outcome due to optimal medical therapy. Topics requiring further research are presented. The implications of the trial for the use of both stress imaging and coronary computed tomography angiography in clinical practice are examined.
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Murthy VL, Bateman TM, Chen W, Malhotra S, Miller EJ, Ruddy TD, Dilsizian V. Impact of the ISCHEMIA Trial on Stress Nuclear Myocardial Perfusion Imaging. J Nucl Med 2020; 61:962-964. [PMID: 32611712 DOI: 10.2967/jnumed.119.245399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Venkatesh L Murthy
- Division of Cardiovascular Medicine and Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Timothy M Bateman
- Mid America Heart Institute and the Saint-Luke's Health System, University of Missouri-Kansas City, Kansas City, Missouri
| | - Wengen Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, Illinois.,Division of Cardiology, Rush Medical College, Chicago, Illinois
| | - Edward J Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; and
| | | | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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The Incremental Role of Coronary Computed Tomography in Chronic Coronary Syndromes. J Clin Med 2020; 9:jcm9123925. [PMID: 33287329 PMCID: PMC7761760 DOI: 10.3390/jcm9123925] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/29/2020] [Accepted: 12/01/2020] [Indexed: 02/03/2023] Open
Abstract
In the context of chronic coronary syndromes (CCS), coronary computed tomography angiography (CCTA) has gained broad acceptance as a noninvasive anatomical imaging tool with ability of excluding coronary stenosis with strong negative predictive value. Atherosclerotic plaque lesions are independent predictors of cardiovascular outcomes in high risk patients with known coronary artery disease (CAD). Calcium detection is commonly expressed through the coronary artery calcium score (CACS), but further research is warranted to confirm the powerness of a CACS-only strategy in both diagnosis and prognosis assessment. Recent studies evidence how defined plaque composition characteristics effectively relate to the risk of plaque instabilization and the overall ischemic burden. Fractional flow reserve from CCTA (FFR-CT) has been demonstrated as a reliable method for noninvasive functional evaluation of coronary lesions severity, while the assessment of perfusion imaging under stress conditions is growing as a useful tool for assessment of myocardial ischemia. Moreover, specific applications in procedural planning of transcatheter valve substitution and follow-up of heart transplantation have gained recent importance. This review illustrates the incremental role of CCTA, which can potentially revolutionize the diagnosis and management pathway within the wide clinical spectrum of CCS.
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Kotecha T, Chacko L, Chehab O, O’Reilly N, Martinez-Naharro A, Lazari J, Knott KD, Brown J, Knight D, Muthurangu V, Hawkins P, Plein S, Moon JC, Xue H, Kellman P, Rakhit R, Patel N, Fontana M. Assessment of Multivessel Coronary Artery Disease Using Cardiovascular Magnetic Resonance Pixelwise Quantitative Perfusion Mapping. JACC Cardiovasc Imaging 2020; 13:2546-2557. [DOI: 10.1016/j.jcmg.2020.06.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 06/04/2020] [Accepted: 06/24/2020] [Indexed: 01/06/2023]
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Kato T, Uemura Y, Naya M, Matsumoto N, Momose M, Hida S, Yamauchi T, Nakajima T, Suzuki E, Inoko M, Shiga T, Tamaki N. Association of coronary revascularisation after physician-referred non-invasive diagnostic imaging tests with outcomes in patients with suspected coronary artery disease: a post hoc subgroup analysis. BMJ Open 2020; 10:e035111. [PMID: 32895263 PMCID: PMC7476491 DOI: 10.1136/bmjopen-2019-035111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the association of the prognostic impact of coronary revascularisation with physician-referred non-invasive diagnostic imaging tests (single photon emission CT (SPECT) vs coronary CT angiography) for coronary artery disease. DESIGN A post hoc analysis of a subgroup from the patient cohort recruited for the Japanese Coronary-Angiography or Myocardial Imaging for Angina Pectoris Study. SETTING Multiple centres in Japan. PARTICIPANTS From the data of 2780 patients with stable angina, enrolled prospectively between January 2006 and March 2008 in Japan, who had undergone physician-referred non-invasive imaging tests, 1205 patients with SPECT as an initial strategy and 625 with CT as an initial strategy were analysed. We assessed the effect of revascularisation (within 90 days) in each diagnostic imaging stratum and the interaction between the two strata. PRIMARY AND SECONDARY OUTCOME MEASURES Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalisation for heart failure and late revascularisation, were followed up for 1 year. The χ2 test, Student's t-test, Kaplan-Meier analysis, log-rank test and multivariable Cox proportional hazard model were used in data analysis. RESULTS A total of 210 (17.4%) patients in the SPECT stratum and 149 (23.8%) in the CT stratum underwent revascularisation. Although in each stratum, the cumulative 1 year incidence of MACEs was significantly higher in patients who underwent revascularisation than in those who did not (SPECT stratum: 9.1 vs 1.2%, log-rank p<0.0001; CT stratum: 6.1 vs 0.8%, log-rank p=0.0001), there was no interaction between the risk of revascularisation and the imaging strata (SPECT stratum: adjusted HR (95% CI), 4.25 (1.86-9.72); CT stratum: 4.13 (1.16-14.73); interaction: p=0.97). CONCLUSION The association of revascularisation with the outcomes of patients with suspected coronary artery disease was not different between SPECT-first and CT-first strategies in a physician-referred fashion.
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Affiliation(s)
- Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Yukari Uemura
- Department of Data Science, National Center for Global Health and Medicine Hospital, Shinjuku-ku, Tokyo, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine School of Medicine, Sapporo, Hokkaido, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Chiyoda, Tokyo, Japan
| | - Mitsuru Momose
- Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University Toyo Medical Research Center, Shinjuku-ku, Tokyo, Japan
| | - Satoshi Hida
- Department of Cardiology, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Takao Yamauchi
- Cardiovascular medicine, Japan Community Healthcare Organization Sagamino Hospital, Sagamihara, Japan
| | - Takatomo Nakajima
- Department of Cardiology, Saitama Cardiovascular and Respiratory Center, Kumagaya, Saitama, Japan
| | - Eriko Suzuki
- Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine School of Medicine, Sapporo, Hokkaido, Japan
| | | | - Tohru Shiga
- Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine School of Medicine, Sapporo, Hokkaido, Japan
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Added Value of Transluminal Attenuation Gradient to Qualitative CCTA Ischemia Detection as Determined by 13N-ammonia PET Quantitative Myocardial Perfusion. Diagnostics (Basel) 2020; 10:diagnostics10090628. [PMID: 32846991 PMCID: PMC7555852 DOI: 10.3390/diagnostics10090628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/18/2020] [Accepted: 08/22/2020] [Indexed: 11/16/2022] Open
Abstract
Transluminal attenuation gradient (TAG) represents the slope of intraluminal contrast that decreases along a coronary vessel during coronary computed tomography angiography (CCTA). The aim of this study was to determine the added value of TAG to qualitative CCTA assessment of significant stenosis (>50%) detecting ischemia as determined by stress myocardial blood flow (MBF) or myocardial flow reserve (MFR) measured by positron emission tomography (PET). Individual contributions of TAG, qualitative assessment and the impact of calcium score were also investigated. Methods: We studied 38 consecutive patients that were referred due to suspected or known coronary artery disease (CAD). All patients underwent a two-phase hybrid 13N-ammonia PET/CT and CCTA. Results: TAG and presence of qualitatively assessed significant stenosis, but not calcium score, were associated with stress myocardial blood flow (MBF) and myocardial flow reserve (MFR). The area under the curves (AUC) of the linear predictor model including qualitative assessment and TAG was superior to the AUC of separate qualitative assessment or TAG for the detection of ischemia according to stress MBF (AUCs were: 88% vs. 79% and 77%; p = 0.01 and p = 0.01, respectively). Conclusions: TAG combined with qualitative CCTA assessment improved ischemia detection.
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Saraste A, Knuuti J. ESC 2019 guidelines for the diagnosis and management of chronic coronary syndromes : Recommendations for cardiovascular imaging. Herz 2020; 45:409-420. [PMID: 32430520 PMCID: PMC7391397 DOI: 10.1007/s00059-020-04935-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of “clinical likelihood of CAD” was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms.
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Affiliation(s)
- Antti Saraste
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamllynkatu 4-8, 20520, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamllynkatu 4-8, 20520, Turku, Finland.
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Comparison of fractional myocardial mass, a vessel-specific myocardial mass-at-risk, with coronary angiographic scoring systems for predicting myocardial ischemia. J Cardiovasc Comput Tomogr 2020; 14:322-329. [DOI: 10.1016/j.jcct.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 08/26/2019] [Accepted: 11/20/2019] [Indexed: 11/23/2022]
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Reynolds HR, Shaw LJ, Min JK, Spertus JA, Chaitman BR, Berman DS, Picard MH, Kwong RY, Bairey-Merz CN, Cyr DD, Lopes RD, Lopez-Sendon JL, Held C, Szwed H, Senior R, Gosselin G, Nair RG, Elghamaz A, Bockeria O, Chen J, Chernyavskiy AM, Bhargava B, Newman JD, Hinic SB, Jaroch J, Hoye A, Berger J, Boden WE, O’Brien SM, Maron DJ, Hochman JS. Association of Sex With Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients With Moderate or Severe Ischemia: Secondary Analysis of the ISCHEMIA Randomized Clinical Trial. JAMA Cardiol 2020; 5:773-786. [PMID: 32227128 PMCID: PMC7105951 DOI: 10.1001/jamacardio.2020.0822] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
Importance While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. Objective To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. Design, Setting, and Participants This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. Interventions CCTA and angina assessment. Main Outcomes and Measures Sex differences in stress test, CCTA findings, and symptom severity. Results Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA) (353 of 1022 [34.4%] vs 378 of 3353 [11.3%]). Of individuals who were randomized, women had more angina at baseline than men (median [interquartile range] Seattle Angina Questionnaire Angina Frequency score: 80 [70-100] vs 90 [70-100]). Women had less severe ischemia on stress imaging (383 of 919 [41.7%] vs 1361 of 2972 [45.9%] with severe ischemia; 386 of 919 [42.0%] vs 1215 of 2972 [40.9%] with moderate ischemia; and 150 of 919 [16.4%] vs 394 of 2972 [13.3%] with mild or no ischemia). Ischemia was similar by sex on exercise tolerance testing. Women had less extensive CAD on CCTA (205 of 568 women [36%] vs 1142 of 2418 men [47%] with 3-vessel disease; 184 of 568 women [32%] vs 754 of 2418 men [31%] with 2-vessel disease; and 178 of 568 women [31%] vs 519 of 2418 men [22%] with 1-vessel disease). Female sex was independently associated with greater angina frequency (odds ratio, 1.41; 95% CI, 1.13-1.76). Conclusions and Relevance Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease. Trial Registration ClinicalTrials.gov Identifier: NCT01471522.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Derek D. Cyr
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Hanna Szwed
- National Institute of Cardiology, Warsaw, Poland
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | | | | | - Ahmed Elghamaz
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia
| | - Jiyan Chen
- Guangdong General Hospital, Guangzhou, China
| | - Alexander M. Chernyavskiy
- E.Meshalkin National medical research center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Moscow, Russia
| | | | | | | | - Joanna Jaroch
- Wroclaw Medical University, T. Marciniak Hospital, Wroclaw, Poland
| | - Angela Hoye
- The University of Hull/Castle Hill Hospital, Cottingham, United Kingdom
| | | | | | | | - David J. Maron
- Department of Medicine, Stanford University, Stanford, California
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Kolentinis M, Le M, Nagel E, Puntmann VO. Contemporary Cardiac MRI in Chronic Coronary Artery Disease. Eur Cardiol 2020; 15:e50. [PMID: 32612708 PMCID: PMC7312615 DOI: 10.15420/ecr.2019.17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/17/2020] [Indexed: 12/12/2022] Open
Abstract
Chronic coronary artery disease remains an unconquered clinical problem, affecting an increasing number of people worldwide. Despite the improved understanding of the disease development, the implementation of the many advances in diagnosis and therapy is lacking. Many clinicians continue to rely on patient’s symptoms and diagnostic methods, which do not enable optimal clinical decisions. For example, echocardiography and invasive coronary catheterisation remain the mainstay investigations for stable angina patients in many places, despite the evidence on their limitations and availability of better diagnostic options. Cardiac MRI is a powerful diagnostic method, supporting robust measurements of crucial markers of cardiac structure and function, myocardial perfusion and scar, as well as providing detailed insight into myocardial tissue. Accurate and informative diagnostic readouts can help with guiding therapy, monitoring disease progress and tailoring the response to treatment. In this article, the authors outline the evidence supporting the state-of-art applications based on cardiovascular magnetic resonance, allowing the clinician optimal use of this insightful diagnostic method in everyday clinical practice.
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Affiliation(s)
- Michalis Kolentinis
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
| | - Melanie Le
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
| | - Eike Nagel
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
| | - Valentina O Puntmann
- Institute of Experimental and Translational Cardiovascular Imaging, German Centre for Cardiovascular Research (DZHK) Centre for Cardiovascular Imaging, Partner Site Rhein-Main, University Hospital Frankfurt Frankfurt, Germany
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After ISCHEMIA: Is cardiac MRI a reliable gatekeeper for invasive angiography and myocardial revascularization? Herz 2020; 45:446-452. [PMID: 32458013 DOI: 10.1007/s00059-020-04936-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This review surveys the findings of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and puts them into a clinical perspective regarding its effect of the role of cardiac magnetic resonance imaging (CMR) as a well-validated gatekeeper for invasive angiography and myocardial revascularization. Noninvasive stress testing of patients with intermediate-to-high pretest likelihood for obstructive coronary artery disease (CAD) using perfusion CMR provides excellent diagnostic accuracy in detecting ischemic myocardium, and additional information from tissue characterization can guide the management of patients with stable angina toward a more individualized therapy as other non-coronary underlying causes of chest pain can be detected. Since ISCHEMIA failed to show that an invasive strategy using percutaneous coronary intervention or coronary artery bypass grafting was associated with an improved prognosis compared with initial conservative medical therapy among stable patients with moderate-to-severe ischemia, CMR as a multifaceted diagnostic imaging approach to explain patients' symptoms should be preferred over anatomical and stress testing alone. Nevertheless, the exclusion of left main coronary artery stenosis either by coronary CT or MR angiography may be required. In conclusion, the results of the ISCHEMIA trial are in good accordance with those of the MR-INFORM trial recently published in the New England Journal of Medicine, as the noninvasive management of a large proportion of patients with CAD was shown to be noninferior to current invasive strategies. Recent outcome data from trials may therefore have an impact on future guidelines to further reduce the execution of unnecessary left heart catheterizations.
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