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Nielsen RV, Fuster V, Bundgaard H, Fuster JJ, Johri AM, Kofoed KF, Douglas PS, Diederichsen A, Shapiro MD, Nicholls SJ, Nordestgaard BG, Lindholt JS, MacRae C, Yuan C, Newby DE, Urbina EM, Bergström G, Ridderstråle M, Budoff MJ, Bøttcher M, Raitakari OT, Hansen TH, Näslund U, Sillesen H, Eldrup N, Ibanez B. Personalized Intervention Based on Early Detection of Atherosclerosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:2112-2127. [PMID: 38777513 DOI: 10.1016/j.jacc.2024.02.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/12/2024] [Accepted: 02/22/2024] [Indexed: 05/25/2024]
Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide and challenges the capacity of health care systems globally. Atherosclerosis is the underlying pathophysiological entity in two-thirds of patients with CVD. When considering that atherosclerosis develops over decades, there is potentially great opportunity for prevention of associated events such as myocardial infarction and stroke. Subclinical atherosclerosis has been identified in its early stages in young individuals; however, there is no consensus on how to prevent progression to symptomatic disease. Given the growing burden of CVD, a paradigm shift is required-moving from late management of atherosclerotic CVD to earlier detection during the subclinical phase with the goal of potential cure or prevention of events. Studies must focus on how precision medicine using imaging and circulating biomarkers may identify atherosclerosis earlier and determine whether such a paradigm shift would lead to overall cost savings for global health.
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Affiliation(s)
- Rikke V Nielsen
- Department of Medical Science, Novo Nordisk Foundation, Hellerup, Denmark; Department of Cardiothoracic Anesthesiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark.
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Mount Sinai Fuster Heart Hospital, New York, New York, USA
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jose J Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; CIBER en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Amer M Johri
- Department of Medicine Queen's University, Kingston, Ontario, Canada
| | - Klaus F Kofoed
- Department of Cardiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark
| | - Pamela S Douglas
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Axel Diederichsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Michael D Shapiro
- Center for Prevention of Cardiovascular Disease, Section on Cardiovascular Disease, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stephen J Nicholls
- Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Børge G Nordestgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Biochemistry and The Copenhagen General Population Study, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark. https://twitter.com/BNordestgaard
| | - Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Elite Research Centre of Individualised Treatment of Arterial Disease (CIMA), Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Calum MacRae
- Harvard Medical School, Department of Medicine, Boston, Massachusetts, USA
| | - Chun Yuan
- Department of Radiology and Imaging Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, Ohio, USA
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, California, USA
| | - Morten Bøttcher
- University Clinic for Cardiovascular Research, Department of Cardiology, Aarhus University/Gødstrup Hospital, Aarhus, Denmark
| | - Olli T Raitakari
- Centre for Population Health Research, Research Centre of Applied and Preventive Cardiovascular Medicine, InFLAMES Research Flagship, University of Turku, Turku, Finland; Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Thomas H Hansen
- Department of Cardiology, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark
| | - Ulf Näslund
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Henrik Sillesen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet University Hospital Copenhagen, Copenhagen, Denmark
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; CIBER en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.
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Williams KJ. Eradicating Atherosclerotic Events by Targeting Early Subclinical Disease: It Is Time to Retire the Therapeutic Paradigm of Too Much, Too Late. Arterioscler Thromb Vasc Biol 2024; 44:48-64. [PMID: 37970716 DOI: 10.1161/atvbaha.123.320065] [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] [Indexed: 11/17/2023]
Abstract
Recent decades have seen spectacular advances in understanding and managing atherosclerotic cardiovascular disease, but paradoxically, clinical progress has stalled. Residual risk of atherosclerotic cardiovascular disease events is particularly vexing, given recognized lifestyle interventions and powerful modern medications. Why? Atherosclerosis begins early in life, yet clinical trials and mechanistic studies often emphasize terminal, end-stage plaques, meaning on the verge of causing heart attacks and strokes. Thus, current clinical evidence drives us to emphasize aggressive treatments that are delayed until patients already have advanced arterial disease. I call this paradigm "too much, too late." This brief review covers exciting efforts that focus on preventing, or finding and treating, arterial disease before its end-stage. Also included are specific proposals to establish a new evidence base that could justify intensive short-term interventions (induction-phase therapy) to treat subclinical plaques that are early enough perhaps to heal. If we can establish that such plaques are actionable, then broad screening to find them in early midlife individuals would become imperative-and achievable. You have a lump in your coronaries! can motivate patients and clinicians. We must stop thinking of a heart attack as a disease. The real disease is atherosclerosis. In my opinion, an atherosclerotic heart attack is a medical failure. It is a manifestation of longstanding arterial disease that we had allowed to progress to its end-stage, despite knowing that atherosclerosis begins early in life and despite the availability of remarkably safe and highly effective therapies. The field needs a transformational advance to shift the paradigm out of end-stage management and into early interventions that hold the possibility of eradicating the clinical burden of atherosclerotic cardiovascular disease, currently the biggest killer in the world. We urgently need a new evidence base to redirect our main focus from terminal, end-stage atherosclerosis to earlier, and likely reversible, human arterial disease.
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Affiliation(s)
- Kevin Jon Williams
- Department of Cardiovascular Sciences, Department of Medicine, Lewis Katz School of Medicine at Temple University, PA
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Antonopoulos AS, Simantiris S. Preventative Imaging with Coronary Computed Tomography Angiography. Curr Cardiol Rep 2023; 25:1623-1632. [PMID: 37897677 DOI: 10.1007/s11886-023-01982-8] [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] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW Coronary computed tomography angiography (CCTA) is the diagnostic modality of choice for patients with stable chest pain. In this review, we scrutinize the evidence on the use of CCTA for the screening of asymptomatic patients. RECENT FINDINGS Clinical evidence suggests that CCTA imaging enhances cardiovascular risk stratification and prompts the timely initiation of preventive treatment leading to reduced risk of major adverse coronary events. Visualization of coronary plaques by CCTA also helps patients to comply with preventive medications. The presence of non-obstructive plaques and total plaque burden are prognostic for cardiovascular events. High-risk plaque features and pericoronary fat attenuation index, enrich the prognostic output of CCTA on top of anatomical information by capturing information on plaque vulnerability and coronary inflammatory burden. Timely detection of atherosclerotic disease or coronary inflammation by CCTA can assist in the deployment of targeted preventive strategies and novel therapeutics to prevent cardiovascular disease.
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Affiliation(s)
- Alexios S Antonopoulos
- Biomedical Research Foundation of the Academy of Athens (BRFAA), 4 Soranou Efesiou Street, Athens, Greece.
- 1st Cardiology Department, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Spyridon Simantiris
- 1st Cardiology Department, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Pugliese L, Ricci F, Sica G, Scaglione M, Masala S. Non-Contrast and Contrast-Enhanced Cardiac Computed Tomography Imaging in the Diagnostic and Prognostic Evaluation of Coronary Artery Disease. Diagnostics (Basel) 2023; 13:2074. [PMID: 37370969 DOI: 10.3390/diagnostics13122074] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
In recent decades, cardiac computed tomography (CT) has emerged as a powerful non-invasive tool for risk stratification, as well as the detection and characterization of coronary artery disease (CAD), which remains the main cause of morbidity and mortality in the world. Advances in technology have favored the increasing use of cardiac CT by allowing better performance with lower radiation doses. Coronary artery calcium, as assessed by non-contrast CT, is considered to be the best marker of subclinical atherosclerosis, and its use is recommended for the refinement of risk assessment in low-to-intermediate risk individuals. In addition, coronary CT angiography (CCTA) has become a gate-keeper to invasive coronary angiography (ICA) and revascularization in patients with acute chest pain by allowing the assessment not only of the extent of lumen stenosis, but also of its hemodynamic significance if combined with the measurement of fractional flow reserve or perfusion imaging. Moreover, CCTA provides a unique incremental value over functional testing and ICA by imaging the vessel wall, thus allowing the assessment of plaque burden, composition, and instability features, in addition to perivascular adipose tissue attenuation, which is a marker of vascular inflammation. There exists the potential to identify the non-obstructive lesions at high risk of progression to plaque rupture by combining all of these measures.
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Affiliation(s)
- Luca Pugliese
- Radiology Unit, Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, 00189 Rome, Italy
| | - Francesca Ricci
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Giacomo Sica
- Radiology Unit, Monaldi Hospital, 80131 Napoli, Italy
| | - Mariano Scaglione
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Salvatore Masala
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
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Bauer MJ, Nano N, Adolf R, Will A, Hendrich E, Martinoff SA, Hadamitzky M. Prognostic Value of Machine Learning-based Time-to-Event Analysis Using Coronary CT Angiography in Patients with Suspected Coronary Artery Disease. Radiol Cardiothorac Imaging 2023; 5:e220107. [PMID: 37124636 PMCID: PMC10141344 DOI: 10.1148/ryct.220107] [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: 05/30/2022] [Revised: 02/09/2023] [Accepted: 02/22/2023] [Indexed: 05/02/2023]
Abstract
Purpose To assess the long-term prognostic value of a machine learning (ML) approach in time-to-event analyses incorporating coronary CT angiography (CCTA)-derived and clinical parameters in patients with suspected coronary artery disease. Materials and Methods The retrospective analysis included patients with suspected coronary artery disease who underwent CCTA between October 2004 and December 2017. Major adverse cardiovascular events were defined as the composite of all-cause death, myocardial infarction, unstable angina, or late revascularization (>90 days after index scan). Clinical and CCTA-derived parameters were assessed as predictors of major adverse cardiovascular events and incorporated into two models: a Cox proportional hazards model with recursive feature elimination and an ML model based on random survival forests. Both models were trained and validated by employing repeated nested cross-validation. Harrell concordance index (C-index) was used to assess the predictive power. Results A total of 5457 patients (mean age, 61 years ± 11 [SD]; 3648 male patients) were evaluated. The predictive power of the ML model (C-index, 0.74; 95% CI: 0.71, 0.76) was significantly higher than the Cox model (C-index, 0.71; 95% CI: 0.68, 0.74; P = .02). The ML model also outperformed the segment stenosis score (C-index, 0.69; 95% CI: 0.66, 0.72; P < .001), which was the best performing CCTA-derived parameter, and patient age (C-index, 0.66; 95% CI: 0.63, 0.69; P < .001), the best performing clinical parameter. Conclusion An ML model for time-to-event analysis based on random survival forests had higher performance in predicting major adverse cardiovascular events compared with established clinical or CCTA-derived metrics and a conventional Cox model.Keywords: Machine Learning, CT Angiography, Cardiac, Arteries, Heart, Arteriosclerosis, Coronary Artery DiseaseSupplemental material is available for this article.© RSNA, 2023.
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Premaratne M, Garcia GP, Thomas W, Hameed S, Leadbeatter A, Htun N, Dwivedi G, Kaye DM. Opportunities and Challenges of Computed Tomography Coronary Angiography in the Investigation of Chest Pain in the Emergency Department-A Narrative Review. Heart Lung Circ 2023; 32:307-314. [PMID: 36621394 DOI: 10.1016/j.hlc.2022.12.004] [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: 05/22/2022] [Revised: 11/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Chest pain is one of the most common presentations to emergency departments. However, only 5.1% will be diagnosed with an acute coronary syndrome, representing considerable time and expense in the diagnosis and investigation of the patients eventually found not to be suffering from an acute coronary syndrome. PubMed and Medline databases were searched with variations of the terms "chest pain", "emergency department", "computed tomography coronary angiography". After review, 52 articles were included. Computed tomography coronary angiography (CTCA) is a class I endorsement for investigating chest pain in major international societal guidelines. CTCA offers excellent sensitivity and negative predictive value in identifying patients with coronary disease, with prognostic data impacting patient management. If CTCA is to be applied to all comers, it is pertinent to discuss the advantages and potential pitfalls if use in the Australian system is to be increased.
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Affiliation(s)
- Manuja Premaratne
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia.
| | | | - William Thomas
- Department of Radiology, Peninsula Health, Melbourne, Vic, Australia
| | - Shaiq Hameed
- Department of Medicine, Peninsula Health, Melbourne, Vic, Australia
| | | | - Nay Htun
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Girish Dwivedi
- Department of Cardiology, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
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Mohammed AA, Zhang H, Abdu FA, Liu L, Singh S, Lv X, Shi T, Mareai RM, Mohammed A, Yin G, Zhang W, Xu Y, Che W. Effect of nonobstructive coronary stenosis on coronary microvascular dysfunction and long-term outcomes in patients with INOCA. Clin Cardiol 2022; 46:204-213. [PMID: 36567512 PMCID: PMC9933113 DOI: 10.1002/clc.23962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ischemic pain with no-obstructive coronary artery (INOCA) is clinically significant and defined by nonobstructive coronary stenosis <50%. Coronary microvascular dysfunction (CMD) is a relevant cause associated with adverse outcomes. OBJECTIVES Investigated the effect of no-stenosis (0% stenosis) and non-obstructive (0% < stenosis < 50%) on the prognostic impact of CMD in INOCA. METHOD A retrospective study assessed the coronary microvascular function in 151 INOCA patients who underwent invasive angiography by the coronary angiography-derived index of microcirculation-resistance (caIMR). CZT-SPECT was performed to evaluate myocardial perfusion imaging (MPI) abnormalities. Chi-square test/Fisher exact test, Student t-test, Kaplan-Meier curve, and Uni-multivariable Cox proportional models were used for analysis. Clinical outcomes were major adverse cardiovascular events (MACE) during a median follow-up of 35 months. RESULT No-stenosis was present in 71 (47%) INOCA patients, and 80 (53%) were with nonobstructive. CMD (caIMR ≥ 25) was more prevalent in patients with no-stenosis than nonobstructive (76.1% vs. 48.8%, p = .001), along with abnormal MPI (39.4% vs. 22.5%, p = .024). The MACE rates were not different between no-stenosis and nonobstructive stenosis. CMD showed an increased risk of MACE for all INOCA. No-stenosis with CMD had the worst prognosis. Cox regression analysis identified CMD and abnormal MPI as predictors of MACE in all INOCA and patients with no-stenosis. However, no-stenosis and nonobstructive stenosis were not predictors of MACE in INOCA. CONCLUSION CMD was more frequently present in INOCA with no-stenosis. However, there was no difference in long-term clinical outcomes between no-stenosis and nonobstructive stenosis. CMD could independently predict poor outcomes in INOCA, particularly in patients with no-stenosis.
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Affiliation(s)
- Ayman A. Mohammed
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina,Department of Internal Medicine, Faculty of Medicine and Health ScienceTaiz UniversityTaizYemen
| | - Hengbin Zhang
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Fuad A. Abdu
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Lu Liu
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Shekhar Singh
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Xian Lv
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Tingting Shi
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Redhwan M. Mareai
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Abdul‐Quddus Mohammed
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Guoqing Yin
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Wen Zhang
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Wenliang Che
- Department of Cardiology, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina,Department of CardiologyShanghai Tenth People's Hospital Chongming branchShanghaiChina
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8
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Long term prognostic value for a normal CCTA. J Cardiovasc Comput Tomogr 2022; 16:531-532. [DOI: 10.1016/j.jcct.2022.07.006] [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: 12/30/2021] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
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Alalawi L, Budoff MJ. Recent Advances in Coronary Computed Tomography Angiogram: The Ultimate Tool for Coronary Artery Disease. Curr Atheroscler Rep 2022; 24:557-562. [PMID: 35507277 DOI: 10.1007/s11883-022-01029-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The emerging technologies in multidetector computed tomography scanners gave the ability to image coronary arteries in a single heartbeat, at a higher quality, and low radiation dose. Furthermore, incorporating artificial intelligence and machine learning into image processing and interpretation have extended the use for coronary computed tomography angiogram (CCTA) and its applications. In this review, we will explore the recent evidence and advances supporting CCTA to become the ultimate tool for coronary artery disease. RECENT FINDINGS Results from the EVINCI, ISCHEMIA, SCOT-HEART, and PROMISE showed that CCTA is better in patients' risk stratification and in detecting subclinical atherosclerosis, resulting in earlier interventions and lesser events. Additionally, CCTA gave us a closer look on atherosclerotic disease by identifying different type of plaque and their clinical significance. Furthermore, FFRCT is a notable example of incorporating artificial intelligence into CCTA. This technology helped us to accurately and non-invasively identify flow limiting lesions, guiding revascularization. As a result of the recent evidence, CCTA have made its way into the chest pain guidelines all over the world. Moreover, CCTA have the potential to revolutionize our understanding and standards in screening, preventing, and managing heart disease.
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Affiliation(s)
- Luay Alalawi
- Department of Cardiology, Lundquist Institute at Harbor UCLA Medical Center, 1209 W 220th St, Torrance, CA, 90502, USA
| | - Matthew J Budoff
- Department of Cardiology, Lundquist Institute at Harbor UCLA Medical Center, 1209 W 220th St, Torrance, CA, 90502, USA.
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Limpijankit T, Jongjirasiri S, Unwanatham N, Rattanasiri S, Thakkinstian A, Laothamatas J. Causal Relationship of Coronary Artery Calcium on Myocardial Infarction and Preventive Effect of Antiplatelet Therapy. Front Cardiovasc Med 2022; 9:871267. [PMID: 35571181 PMCID: PMC9091507 DOI: 10.3389/fcvm.2022.871267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background The role of coronary artery calcium score (CACS) to guide antiplatelet therapy in order to prevent myocardial infarction (MI) is still uncertain. This study aimed to find the causal relationship of CACS on MI and preventive effect of antiplatelet therapy. Methods From 2005 to 2013, all patients with cardiovascular risk factors or symptoms of suspected CAD underwent coronary computed tomography. CACSs were measured using Agatston method and stratified into 4 groups: 0, 1–99, 100–399, and ≥ 400. Antiplatelet therapy was prescribed following physician discretion. Outcomes of interest were MI and bleeding. A mediation analysis was applied to find association pathways. CACS was considered as an independent variable, whereas antiplatelet therapy was considered as a mediator and MI considered the outcome of interest. Results A total of 7,849 subjects were enrolled. During an average of 9.9 ± 2.4 years follow-up, MI and bleeding events occurred in 2.24% (n = 176) and 2.82% (n = 221) of subjects, respectively. CACSs 100–399 and CAC ≥ 400 were significantly associated with the development of MI [OR 3.14 (1.72, 5.72), and OR 3.22 (1.66, 6.25), respectively, p < 0.001]. Antiplatelet therapy reduced the risk of MI of these corresponding CAC groups with ORs of 0.60 (0.41, 0.78) and 0.56 (0.34, 0.77), p < 0.001]. A risk of bleeding was associated with antiplatelet therapy (only aspirin), anticoagulant, hypertension, male gender and old age. Conclusion CACS was associated with the development of future MI. The preventive effect of antiplatelet therapy was clearly demonstrated in subjects with CACSs equal to or above 100, but this benefit was partially offset by an increased risk of bleeding.
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Affiliation(s)
- Thosaphol Limpijankit
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
- *Correspondence: Thosaphol Limpijankit,
| | - Sutipong Jongjirasiri
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Nattawut Unwanatham
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Thailand
| | - Jiraporn Laothamatas
- Faculty of Heath Science Technology, Chulabhorn Royal Academy, Bangkok, Thailand
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I. Eur Heart J Cardiovasc Imaging 2022; 23:299-314. [PMID: 35076061 PMCID: PMC8863074 DOI: 10.1093/ehjci/jeab293] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/14/2021] [Indexed: 01/26/2023] Open
Abstract
Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.
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Affiliation(s)
- Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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Qiao HY, Tang CX, Schoepf UJ, Bayer RR, Tesche C, Di Jiang M, Yin CQ, Zhou CS, Zhou F, Lu MJ, Jiang JW, Lu GM, Ni QQ, Zhang LJ. One-year outcomes of CCTA alone versus machine learning-based FFR CT for coronary artery disease: a single-center, prospective study. Eur Radiol 2022; 32:5179-5188. [PMID: 35175380 DOI: 10.1007/s00330-022-08604-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/25/2021] [Accepted: 01/20/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To explore downstream management and outcomes of machine learning (ML)-based CT derived fractional flow reserve (FFRCT) strategy compared with an anatomical coronary computed tomography angiography (CCTA) alone assessment in participants with intermediate coronary artery stenosis. METHODS In this prospective study conducted from April 2018 to March 2019, participants were assigned to either the CCTA or FFRCT group. The primary endpoint was the rate of invasive coronary angiography (ICA) that demonstrated non-obstructive disease at 90 days. Secondary endpoints included coronary revascularization and major adverse cardiovascular events (MACE) at 1-year follow-up. RESULTS In total, 567 participants were allocated to the CCTA group and 566 to the FFRCT group. At 90 days, the rate of ICA without obstructive disease was higher in the CCTA group (33.3%, 39/117) than that (19.8%, 19/96) in the FFRCT group (risk difference [RD] = 13.5%, 95% confidence interval [CI]: 8.4%, 18.6%; p = 0.03). The ICA referral rate was higher in the CCTA group (27.5%, 156/567) than in the FFRCT group (20.3%, 115/566) (RD = 7.2%, 95% CI: 2.3%, 12.1%; p = 0.003). The revascularization-to-ICA ratio was lower in the CCTA group than that in the FFRCT group (RD = 19.8%, 95% CI: 14.1%, 25.5%, p = 0.002). MACE was more common in the CCTA group than that in the FFRCT group at 1 year (HR: 1.73; 95% CI: 1.01, 2.95; p = 0.04). CONCLUSION In patients with intermediate stenosis, the FFRCT strategy appears to be associated with a lower rate of referral for ICA, ICA without obstructive disease, and 1-year MACE when compared to the anatomical CCTA alone strategy. KEY POINTS • In stable patients with intermediate stenosis, ML-based FFRCT strategy was associated with a lower referral ICA rate, a lower normalcy rate of ICA, and higher revascularization-to-ICA ratio than the CCTA strategy. • Compared with the CCTA strategy, ML-based FFRCTshows superior outcome prediction value which appears to be associated with a lower rate of 1-year MACE. • ML-based FFRCT strategy as a non-invasive "one-stop-shop" modality may be the potential to change diagnostic workflows in patients with suspected coronary artery disease.
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Affiliation(s)
- Hong Yan Qiao
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.,Department of Medical Imaging, Affiliated Hospital of Jiangnan University, Wuxi, 214041, Jiangsu, China
| | - Chun Xiang Tang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - Richard R Bayer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA.,Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany.,Department of Internal Medicine, St. Johannes-Hospital, Dortmund, Germany
| | - Meng Di Jiang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Chang Qing Yin
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Chang Sheng Zhou
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Fan Zhou
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Meng Jie Lu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Jian Wei Jiang
- Department of Medical Imaging, Affiliated Hospital of Jiangnan University, Wuxi, 214041, Jiangsu, China
| | - Guang Ming Lu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
| | - Qian Qian Ni
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Long Jiang Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
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Zhou F, Chen Q, Luo X, Cao W, Li Z, Zhang B, Schoepf UJ, Gill CE, Guo L, Gao H, Li Q, Shi Y, Tang T, Liu X, Wu H, Wang D, Xu F, Jin D, Huang S, Li H, Pan C, Gu H, Xie L, Wang X, Ye J, Jiang J, Zhao H, Fang X, Xu Y, Xing W, Li X, Yin X, Lu GM, Zhang LJ. Prognostic Value of Coronary CT Angiography-Derived Fractional Flow Reserve in Non-obstructive Coronary Artery Disease: A Prospective Multicenter Observational Study. Front Cardiovasc Med 2022; 8:778010. [PMID: 35174219 PMCID: PMC8843039 DOI: 10.3389/fcvm.2021.778010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/06/2021] [Indexed: 01/17/2023] Open
Abstract
Coronary artery disease (CAD) is a major contributor to morbidity and mortality worldwide. Myocardial ischemia may occur in patients with normal or non-obstructive CAD on invasive coronary angiography (ICA). The comprehensive evaluation of coronary CT angiography (CCTA) integrated with fractional flow reserve derived from CCTA (CT-FFR) to CAD may be essential to improve the outcomes of patients with non-obstructive CAD. China CT-FFR Study-2 (ChiCTR2000031410) is a large-scale prospective, observational study in 29 medical centers in China. The primary purpose is to uncover the relationship between the CCTA findings (including CT-FFR) and the outcome of patients with non-obstructive CAD. At least 10,000 patients with non-obstructive CAD but without previous revascularization will be enrolled. A 5-year follow-up will be performed. The primary endpoint is the occurrence of major adverse cardiovascular events (MACE), including all-cause mortality, non-fatal myocardial infarct, unplanned revascularization, and hospitalization for unstable angina. Clinical characteristics, laboratory and imaging examination results will be collected to analyze their prognostic value.
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Affiliation(s)
- Fan Zhou
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qian Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao Luo
- Department of Radiology, People's Hospital of Maanshan, Maanshan, China
| | - Wei Cao
- Department of Radiology, The First People's Hospital of Xuzhou, Xuzhou, China
| | - Ziwen Li
- Department of Radiology, Lianyungang Clinical Medical College of Nanjing Medical University, Lianyungang, China
| | - Bo Zhang
- Department of Radiology, Taizhou People's Hospital, Taizhou, China
| | - U. Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, United States
| | - Callum E. Gill
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, United States
| | - Lili Guo
- Department of Medical Imaging, The Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Hong Gao
- Department of Medical Imaging, Qinhuai Medical Region of Jinling Hospital, Nanjing, China
| | - Qingyao Li
- Department of Radiology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yibing Shi
- Department of Diagnostic Radiology, Xuzhou Central Hospital, Xuzhou, China
| | - Tingting Tang
- Department of Diagnostic Radiology, Yancheng No.1 Hospital, Affiliated Hospital of Nantong University, Yancheng, China
| | - Xiaochen Liu
- Department of Medical Imaging, Hai'an City People's Hospital, Haian, China
| | - Honglin Wu
- Department of Radiology, The Affiliated Wujin Hospital of Jiangsu University, Changzhou, China
| | - Dongqing Wang
- Department of Medical Imaging, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Feng Xu
- Department of Medical Imaging, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, China
| | - Dongsheng Jin
- Department of Radiology, Jiangsu Province Official Hospital, Jiangsu Jiankang Vocational College, Nanjing, China
| | - Sheng Huang
- Department of Radiology, The Second Affiliated Hospital of Nantong University, Nantong, China
| | - Haige Li
- Department of Medical Imaging, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changjie Pan
- Department of Radiology, The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Hongmei Gu
- Medical Imaging Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Lixiang Xie
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ximing Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Ye
- Radiology Department, Subei People's Hospital of Jiangsu Province, Yangzhou, China
| | - Jianwei Jiang
- Department of Medical Imaging, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Hanqing Zhao
- Department of Medical Imaging, The Affiliated Huaihai Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiangming Fang
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Yi Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Xing
- Department of Radiology, Third Affiliated Hospital of Soochow University, Soochow University, Changzhou, China
| | - Xiaohu Li
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Xiaohu Li
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Xindao Yin
| | - Guang Ming Lu
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- Guang Ming Lu
| | - Long Jiang Zhang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- *Correspondence: Long Jiang Zhang
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Lee JE, Park HM, Lim Y, Jeong WGI, Kim YH. Pathophysiology and Role of Coronary CT Angiography in Stable Angina. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:42-53. [PMID: 36237352 PMCID: PMC9238201 DOI: 10.3348/jksr.2021.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/11/2021] [Accepted: 12/24/2021] [Indexed: 11/28/2022]
Abstract
관상동맥질환의 임상적인 개념은 지난 10년 동안 패러다임의 변화를 보여왔다. 관상동맥질환은 대부분 진행성 질환이며, 관상동맥질환 환자는 질병 진행의 어느 시점에서도 급성 관상동맥 증후군에 직면할 수 있다. 이러한 임상적 맥락에서 2019년 유럽심장학회 가이드라인에서는 조기 진단과 꾸준한 관리가 필요한 관상동맥질환의 임상적인 중요성을 반영하여 “만성 관상동맥증후군”이라는 용어의 사용을 발표하였다. 최근 관상동맥 전산화단층촬영 혈관조영술을 이용한 관상동맥질환의 평가는 많은 발전을 이루었고, 안정형 협심증 또는 만성 관상동맥증후군 환자에서 관상동맥 전산화단층촬영 혈관조영술의 임상적 유용성은 초기 무증상 관상동맥질환의 발견에서부터 죽상경화판의 특성 분석 및 관상동맥질환의 치료 전략 결정에 도움을 주는 역할까지 관상동맥질환의 다양한 단계에 걸쳐 입증되고 있다. 이 종설에서는 안정형 협심증 환자의 이해를 돕는 병태생리를 설명하고 이에 대한 관상동맥 전산화단층촬영의 임상적 적용과 역할에 대해 알아보고자 한다.
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Affiliation(s)
- Jong Eun Lee
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hye Mi Park
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Yongwhan Lim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Won GI Jeong
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yun-Hyeon Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
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15
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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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16
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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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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the 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 studies, 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. These guidelines present 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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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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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: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the 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 studies, 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. These guidelines present 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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Yu MM, Tang XL, Jin H, Yang S, Yun H, Wang QB, Zeng MS. Coronary CT Angiography in Asymptomatic Adults with Hepatic Steatosis. Radiology 2021; 301:593-601. [PMID: 34546127 DOI: 10.1148/radiol.2021210355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The long-term prognostic value of coronary CT angiography (CCTA) in asymptomatic adults with hepatic steatosis (HS) remains unknown. Purpose To evaluate the long-term prognostic value of CCTA in asymptomatic adults with HS. Materials and Methods Between January 2009 and December 2013, consecutive asymptomatic adults who underwent CCTA evaluation and unenhanced abdominal CT were prospectively enrolled. All participants were divided into two groups-with HS and without HS according to abdominal CT results. The primary end point was major adverse cardiovascular events (MACEs), defined as cardiac death, stroke, myocardial infarction, and angina requiring hospitalization. Multivariable Cox regression analysis and Kaplan-Meier analysis were used to compare survival rates. Results One thousand thirteen participants with HS and 1940 participants without HS who completed the follow-up were included (mean age, 66 years ± 10 [standard deviation] [range, 29-90 years]; 1940 men). During a median of 7.2 years of follow-up (interquartile range, 6.3-8.1), MACEs were observed in 96 of 1013 participants with HS (10%), whereas 80 of 1940 participants without HS (4%) had MACEs. In participants with a Coronary Artery Disease Reporting and Data System (CAD-RADS) category of 0, both participants with and without HS had a similar 8.8-year event-free survival rate (99.2% event-free survival rate in participants with HS vs 99.0% event-free survival rate in participants without HS, P = .77). As for participants with CAD-RADS categories 1 or 2 or 3-5, the 8.8-year event-free survival rate was lower in participants with HS than in those without HS (70.6% vs 85.2%, P < .001; 51.4% vs 71.7%, P = .03, respectively). The risk of MACEs was higher for participants with HS than for those without HS in CAD-RADS categories 1 and 2 (adjusted hazard ratio = 2.3; 95% CI: 1.4, 3.9; P < .001) and CAD-RADS categories 3-5 (adjusted HR = 2.1; 95% CI: 1.2, 3.6; P = .006) but not in the setting of CAD-RADS category 0 (adjusted HR = 5.1; 95% CI: 0.1, 398; P = .47). Conclusion Asymptomatic participants with hepatic steatosis (HS) had a worse prognosis than those without HS in the presence of coronary artery disease (CAD) at coronary CT angiography, whereas participants with HS and without CAD might have excellent clinical outcomes during a median follow-up of 7.2 years. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Meng-Meng Yu
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
| | - Xiang-Lin Tang
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
| | - Hang Jin
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
| | - Shan Yang
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
| | - Hong Yun
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
| | - Qi-Bing Wang
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
| | - Meng-Su Zeng
- From the Departments of Radiology (M.M.Y., H.J., S.Y., H.Y., M.S.Z.) and Cardiology (X.L.T., Q.B.W.), Zhongshan Hospital, Fudan University and Shanghai Medical Imaging Institute, 180 Fenglin Rd, Shanghai 200032, China
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21
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Coronary computed tomography angiography in patients with stable coronary artery disease. Trends Cardiovasc Med 2021; 32:421-428. [PMID: 34454051 DOI: 10.1016/j.tcm.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/20/2021] [Accepted: 08/20/2021] [Indexed: 01/07/2023]
Abstract
The treatment of coronary artery disease (CAD), which is defined by stable anatomical atherosclerotic and functional alterations of epicardial vessels or microcirculation, focuses on managing intermittent angina symptoms and preventing major adverse cardiovascular events with optimal medical therapy. When patients with known CAD present with angina and no acute coronary syndrome, they have historically been evaluated with a variety of noninvasive stress tests that utilize electrocardiography, radionuclide scintigraphy, echocardiography, or magnetic resonance imaging for determining the presence and extent of inducible myocardial ischemia. Patient event-free survival, however, is largely driven by the coronary atherosclerotic disease burden, which is not directly assessed by functional testing. Direct evaluation of coronary atherosclerotic disease by coronary computed tomography angiography (coronary CTA) has emerged as the first line noninvasive imaging modality as it improves diagnostic accuracy and positively influences clinical management. Compared to functional assessment of CAD, coronary CTA-guided management results in improved patient outcomes by facilitating prevention of myocardial infarction. Other strengths of coronary CTA include detailed atherosclerotic plaque characterization and the ability to assess functional significance of specific lesions, which may further improve risk assessment and prognosis and lead to more appropriate referrals for additional testing, such as invasive coronary angiography.
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22
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Deseive S, Kupke M, Straub R, Stocker TJ, Broersen A, Kitslaar P, Martinoff S, Massberg S, Hadamitzky M, Hausleiter J. Quantified coronary total plaque volume from computed tomography angiography provides superior 10-year risk stratification. Eur Heart J Cardiovasc Imaging 2021; 22:314-321. [PMID: 32793952 DOI: 10.1093/ehjci/jeaa228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/23/2020] [Indexed: 01/17/2023] Open
Abstract
AIMS Automated coronary total plaque volume (TPV) quantification derived from coronary computed tomographic angiography (CTA) datasets provide exact and reliable assessment of calcified and non-calcified coronary atherosclerosis burden. The aim of this analysis was to investigate the long-term predictive value of TPV. METHODS AND RESULTS TPV was quantified in 1577 patients undergoing coronary CTA and cardiovascular events were collected during 10.5 years (interquartile range 6.0-11.4) of follow-up. The study endpoint comprised cardiac death and acute coronary syndrome and occurred in 59 (3.7%) patients. Coronary TPV provided additive prognostic value over clinical risk assessed with the Morise Score and coronary artery disease severity (rise in C-index from 0.744 to 0.769, P = 0.03). A category-based reclassification approach combining the Morise Score and TPV revealed superior risk stratification (categorical net reclassification improvement: 0.48 with 95% CI 0.13-0.68, P < 0.001) and resulted in reclassification of 800 (51%) patients compared with the Morise Score alone. The 10-year risk for the study endpoint was 0.6% (95% CI 0-1.3) for patients classified as low risk (n = 807), 4.8% (95% CI 2.4-7.2) for patients at intermediate risk (n = 400), and 10.3% (95% CI 6.6-13.9) for patients at high risk (n = 370) using the combined reclassification approach. CONCLUSION Quantification of TPV from coronary CTA permits an improved 10-year cardiovascular risk stratification.
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Affiliation(s)
- Simon Deseive
- Medizinische Klinik und Poliklinik I der Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 Munich, Germany
- Munich Heart Alliance at DZHK, Munich, Germany
| | - Maximilian Kupke
- Medizinische Klinik und Poliklinik I der Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Ramona Straub
- Medizinische Klinik und Poliklinik I der Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Thomas J Stocker
- Medizinische Klinik und Poliklinik I der Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 Munich, Germany
- Munich Heart Alliance at DZHK, Munich, Germany
| | - Alexander Broersen
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter Kitslaar
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Medis Medical Imaging Systems BV, Leiden, The Netherlands
| | - Stefan Martinoff
- Division of Radiology, Deutsches Herzzentrum München, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I der Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 Munich, Germany
- Munich Heart Alliance at DZHK, Munich, Germany
| | - Martin Hadamitzky
- Division of Radiology, Deutsches Herzzentrum München, Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I der Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 Munich, Germany
- Munich Heart Alliance at DZHK, Munich, Germany
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23
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Hanson CA, Lu E, Ghumman SS, Ouellette ML, Löffler AI, Beller GA, Bourque JM. Long-term outcomes in patients with normal coronary arteries, nonobstructive, or obstructive coronary artery disease on invasive coronary angiography. Clin Cardiol 2021; 44:1286-1295. [PMID: 34216037 PMCID: PMC8428062 DOI: 10.1002/clc.23686] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Normal or near normal coronary arteries (NNCA) or nonobstructive coronary artery disease (CAD) are commonly found on invasive coronary angiography (ICA). Hypothesis We aimed to determine long‐term outcomes by severity of CAD in a contemporary cohort of patients undergoing ICA for evaluation for ischemic heart disease. Methods We assessed a consecutive cohort of 925 patients who underwent non‐emergent ICA over 24 months. Cardiac death (CD), nonfatal myocardial infarction (NFMI), late revascularization, and medication use were assessed. Results Follow‐up data was available in 850 patients. Of patients without heart failure, at a median of 6.0 years, there was a significant decrease in survival free from CD or NFMI, and from all cardiac events, for those with obstructive CAD compared with patients with NNCAs or nonobstructive CAD (p < .001 for both). No differences between NNCA and nonobstructive CAD patients in rates of CD or NFMI (2.0% vs. 2.1%/year, p = .58) or all cardiac events (2.4% vs. 2.9%/year, p = .84) were observed. Conclusion Long‐term follow‐up in a contemporary cohort of consecutive patients undergoing non‐emergent ICA for detection of CAD showed no difference in annual rates of CD or NFMI, or total cardiac events, in patients with NNCAs versus those with nonobstructive CAD, whereas patients with obstructive CAD had significantly more events. Event rates were low and similar by gender. Use of aspirin, lipid lowering therapy, and beta‐blockers increased in all subgroups after ICA. We speculate this may explain the low incidence of subsequent cardiac events, and similar event rates in patients with NNCA and nonobstructive CAD, even in patients presenting with non‐ST‐elevation MI.
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Affiliation(s)
- Christopher A Hanson
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Edwin Lu
- Department of Medicine, University of North Carolina Health System, Chapel Hill, North Carolina, USA
| | - Saad S Ghumman
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michelle L Ouellette
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Adrián I Löffler
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - George A Beller
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jamieson M Bourque
- Department of Medicine, Cardiovascular Division, University of Virginia Health System, Charlottesville, Virginia, USA.,Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
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24
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Slim AM, Fentanes E, Cheezum MK, Parsons IT, Maroules C, Chen B, Abbara S, Branch K, Nagpal P, Shah NR, Thomas DM, Villines TC, Blankstein R, Shaw LJ, Budoff M, Nicol E. The role of cardiovascular CT in occupational health assessment for coronary heart disease: An expert consensus document from the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr 2021; 15:290-303. [PMID: 33926854 DOI: 10.1016/j.jcct.2021.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | | | | | | | | | - Billy Chen
- Cedars-Sinai Medical Center, Baldwin Park, CA, USA
| | - Suhny Abbara
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Prashant Nagpal
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nishant R Shah
- Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Dustin M Thomas
- Parkview Health, Parkview Research Center, Fort Wayne, IN, USA
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Ed Nicol
- Royal Brompton Hospital, London, UK
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25
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Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman DS, Blankstein R, Leipsic J, Newby D, Nicol ED, Nieman K, Shaw L, Villines TC, Williams M, Hecht HS. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021; 15:192-217. [PMID: 33303384 PMCID: PMC8713482 DOI: 10.1016/j.jcct.2020.11.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Y Chandrashekhar
- University of Minnesota and VA Medical Center, Minneapolis, MN, USA
| | - Amir Ahmadi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suhny Abbara
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Ron Blankstein
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - David Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Edward D Nicol
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Leslee Shaw
- New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | - Michelle Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Harvey S Hecht
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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26
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Rodríguez-Capitán J, Sánchez-Pérez A, Ballesteros-Pradas S, Millán-Gómez M, Cardenal-Piris R, Oneto-Fernández M, Gutiérrez-Alonso L, Rivera-López R, Guisado-Rasco A, Cano-García M, Gutiérrez-Bedmar M, Jiménez-Navarro M. Prognostic Implication of Non-Obstructive Coronary Lesions: A New Classification in Different Settings. J Clin Med 2021; 10:jcm10091863. [PMID: 33923110 PMCID: PMC8123418 DOI: 10.3390/jcm10091863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/25/2022] Open
Abstract
The clinical significance of non-obstructive coronary artery disease is the subject of debate. Our objective was to evaluate the long-term cardiovascular prognosis associated with non-obstructive coronary artery disease in patients undergoing coronary angiography, and to conduct a stratification by sex, diabetes, and clinical indication. We designed a multi-centre retrospective longitudinal observational study of 3265 patients that were classified into three groups: normal coronary arteries (lesion <20%, 1426 patients), non-obstructive coronary artery disease (20–50%, 643 patients), and obstructive coronary artery disease (>70%, 1196 patients). During a mean follow-up of 43 months, we evaluated a combined cardiovascular event: acute myocardial infarction, stroke, hospitalization for heart failure, or cardiovascular death. Multivariable-adjusted Cox proportional hazard models showed a worse prognosis in patients with non-obstructive coronary artery disease, in comparison with patients of normal coronary arteries group, in the total population (hazard ratio 1.72, 95% confidence interval 1.23–2.39; p for trend <0.001), in non-diabetics (hazard ratio 2.12, 95% confidence interval: 1.40–3.22), in women (hazard ratio 1.75, 95% confidence interval 1.10–2.77), and after acute coronary syndrome (hazard ratio 2.07, 95% confidence interval 1.25–3.44). In conclusion, non-obstructive coronary artery disease is associated with an impaired long-term cardiovascular prognosis. This association held for non-diabetics, women, and after acute coronary syndrome.
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Affiliation(s)
- Jorge Rodríguez-Capitán
- Área del Corazón, UMA Campus de Teatinos S/N, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA, 29010 Málaga, Spain; (J.R.-C.); (A.S.-P.); (M.M.-G.)
| | - Andrés Sánchez-Pérez
- Área del Corazón, UMA Campus de Teatinos S/N, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA, 29010 Málaga, Spain; (J.R.-C.); (A.S.-P.); (M.M.-G.)
| | | | - Mercedes Millán-Gómez
- Área del Corazón, UMA Campus de Teatinos S/N, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA, 29010 Málaga, Spain; (J.R.-C.); (A.S.-P.); (M.M.-G.)
| | - Rosa Cardenal-Piris
- Hospital Universitario Juan Ramón Jiménez, Ronda Norte S/N, 21005 Huelva, Spain;
| | | | - Lola Gutiérrez-Alonso
- Hospital Universitario Puerta del Mar, Cádiz, Avenida Ana de Viya 21, 11009 Cádiz, Spain;
| | - Ricardo Rivera-López
- Servicio de Cardiología, Instituto de Investigación Biosanitaria (Ibs), Hospital Universitario Virgen de las Nieves, Avenida de las Fuerzas Armadas 2, 18014 Granada, Spain;
| | - Agustín Guisado-Rasco
- Hospital Universitario Virgen del Rocío, CIBERCV, Avenida Manuel Siurot S/N, 41013 Sevilla, Spain;
| | - Macarena Cano-García
- Hospital Regional Universitario de Málaga, Avenida de Carlos Haya 84, 29010 Málaga, Spain;
| | - Mario Gutiérrez-Bedmar
- Department of Preventive Medicine and Public Health, School of Medicine, Campus de Teatinos S/N, University of Málaga, 29010 Málaga, Spain
- Correspondence: (M.G.-B.); (M.J.-N.); Tel.: +34-952-137-387 (M.G.-B.); +34-951-032-054 (M.J.-N.)
| | - Manuel Jiménez-Navarro
- Área del Corazón, UMA Campus de Teatinos S/N, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA, 29010 Málaga, Spain; (J.R.-C.); (A.S.-P.); (M.M.-G.)
- Correspondence: (M.G.-B.); (M.J.-N.); Tel.: +34-952-137-387 (M.G.-B.); +34-951-032-054 (M.J.-N.)
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27
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Choi YJ, Park JB, Park CS, Hwang I, Yoon YE, Lee SP, Kim HK, Kim YJ, Cho GY, Sohn DW. Prognostic implications of left ventricular mass-geometry in patients with no or nonobstructive coronary artery disease. BMC Cardiovasc Disord 2021; 21:187. [PMID: 33858344 PMCID: PMC8051046 DOI: 10.1186/s12872-021-02005-6] [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: 12/15/2020] [Accepted: 04/09/2021] [Indexed: 12/28/2022] Open
Abstract
Background Coronary computed tomography angiography (CCTA) is widely used as a first-line noninvasive modality that frequently exhibits no or nonobstructive coronary artery disease (CAD) in clinical practice, along with abnormal left ventricular (LV) geometry on echocardiography. However, the combined prognostic value of these findings has not been well elucidated. Therefore, we aimed to evaluate the prognostic implications of abnormal LV geometry in individuals with no or nonobstructive CAD. Methods A total of 5806 subjects with no CAD or nonobstructive CAD (luminal narrowing < 50%) on CCTA were included in the study. The major exclusion criteria were structural heart disease and a history of myocardial infarction or coronary revascularization. Abnormal LV geometry on echocardiography was defined as LV mass index > 95 g/m2 in women and > 115 g/m2 in men, and/or relative wall thickness > 0.42. The primary outcome was all-cause mortality. Results A total of 5803 subjects without significant obstructive CAD (age, 56.6 ± 8.87 years; men, 3884 [66.9%]). Of them, 4045 (69.7%) subjects had normal LV geometry and 1758 (30.3%) had abnormal LV geometry respectively. During a mean follow-up of 6.2 ± 1.48 years, 84 (1.44%) subjects died in the study population. Of these, 56 subjects were from the normal LV geometry group (1.24%) and 28 were from the abnormal LV geometry group (2.32%). Subjects with abnormal LV geometry had significantly worse survival rates (log-rank, p < 0.001). After adjustment for confounding factors, abnormal LV geometry was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.64; 95% confidence interval, 1.04–2.58; p = 0.034). Moreover, abnormal LV geometry was significantly worse in survival when classified as those with no CAD (log-rank, p = 0.024) and nonobstructive CAD (Log-rank, p < 0.001). Conclusions Abnormal LV geometry portends a worse prognosis in subjects with no or nonobstructive CAD. These findings suggest that LV geometry assessment can help improve the stratification of individuals with these CCTA findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02005-6.
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Affiliation(s)
- You-Jung Choi
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - Chan Soon Park
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Graduated School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Inchang Hwang
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Seung-Pyo Lee
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Yong-Jin Kim
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Goo-Yeong Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea.,Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Dae-Won Sohn
- Division of Cardiology, Department of Internal Medicine/Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University, Seoul, Republic of Korea
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28
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Nicol ED, Feuchtner GM, Villines TC. Following the evidence: The pre-eminent role of coronary CT angiography in 2021. J Cardiovasc Comput Tomogr 2021; 15:285-287. [PMID: 33811015 DOI: 10.1016/j.jcct.2021.03.009] [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] [Indexed: 11/24/2022]
Affiliation(s)
- Edward D Nicol
- Department of Cardiovascular CT, Royal Brompton Hospital, London, UK; Faculty of Medicine, Imperial College, London, UK.
| | - Gudrun M Feuchtner
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - Todd C Villines
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
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29
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What Is of Recent Interest in Cardiac CTA? J Am Coll Cardiol 2020; 76:3056-3060. [PMID: 33334427 DOI: 10.1016/j.jacc.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Ateş AH, Yorgun H, Canpolat U, Kaya EB, Şahiner L, Hazirolan T, Dural M, Okşul M, Şener YZ, Karahan S, Aytemir K. Long-Term Prognostic Value of Coronary Atherosclerotic Plaque Characteristics Assessed by Computerized Tomographic Angiography. Angiology 2020; 72:252-259. [PMID: 33118364 DOI: 10.1177/0003319720963677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We aimed to present the long-term prognostic role of coronary computed tomography angiography (CTA) in a cohort of patients with coronary artery disease (CAD) and noncritical stenosis. A total of 1138 patients who underwent coronary CTA for suspected CAD were included in the study. For the categorization of the coronary atherosclerotic plaque (CAP), the coronary system was divided into 16 segments. For each segment, CAPs were categorized as calcified, noncalcified, and mixed. All-cause and cardiovascular (CV) mortality data were collected for prognostic evaluation. Coronary CTA analyses showed that 34.5% of patients had noncalcified CAP, 14.5% of patients had calcified CAP, and 11% of patients had mixed CAP. During a median of 141.5 months follow-up, CV and all-cause mortality was observed in 57 (5%) and 149 (13.1%) patients, respectively. In multivariable Cox regression analysis, calcified CAP morphology and the extent of involved segments were significant predictors of both CV and all-cause mortality. The presence of calcified CAP morphology and the higher number of diseased coronary segments via coronary CTA might help stratify patients at risk for adverse CV outcomes during long-term follow-up. Patients with these features at index coronary CTA may be evaluated more closely with aggressive preventive measures.
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Affiliation(s)
- Ahmet Hakan Ateş
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hikmet Yorgun
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Uğur Canpolat
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ergun Baris Kaya
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Levent Şahiner
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tuncay Hazirolan
- Department of Radiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Muhammet Dural
- Department of Cardiology, 64063Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Metin Okşul
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yusuf Ziya Şener
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sevilay Karahan
- Department of Biostatistics, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, 37515Hacettepe University Faculty of Medicine, Ankara, Turkey
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31
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Prognostic Implications of Coronary CT Angiography: 12-Year Follow-Up of 6892 Patients. AJR Am J Roentgenol 2020; 215:818-827. [DOI: 10.2214/ajr.19.22578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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32
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Faber M, Will A, Hendrich E, Martinoff S, Hadamitzky M. Sex- and age-specific differences in the long-term prognostic value of morphological plaque features detected by coronary computed tomography angiography. J Cardiovasc Comput Tomogr 2020; 15:274-280. [PMID: 32980279 DOI: 10.1016/j.jcct.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although sex- and age-specific differences in coronary plaque features detected by coronary computed tomography angiography (CCTA) are known, insufficient information regarding the long-term prognostic value of these findings exists. METHODS A total of 1615 patients with suspected but not previously diagnosed coronary artery disease (CAD) were examined by CCTA and coronary plaque features were assessed. The median follow-up period was 10.5 (IQR 9.2-11.4) years. Cox proportional-hazards analysis was used for the combined endpoint of cardiac death or nonfatal myocardial infarction. RESULTS The endpoint occurred more often in patients older than 65 years (5.66% vs. 2.05%; p = 0.00029) but similarly between female (3.34%) and male (3.07%) patients (p = 0.76). Both sexes displayed a similar prevalence for noncalcified (female vs. male: 0.77 ± 1.38 vs. 0.89 ± 1.41; p = 0.098) and low-attenuation (female vs. male: 2.6% vs. 4.37%; p = 0.096) plaques. As assessed by p for interaction CADRADS (p for interaction = 0.013), noncalcified plaques (p for interaction = 0.022) and low-attenuation plaques (p for interaction = 0.045) had a better primary endpoint association in women than in men. Concerning age, no difference in outcome association was apparent as evaluated by p for interaction. CONCLUSION CCTA demonstrates excellent long-term prognostic value irrespective of sex and age and independent from the higher prevalence of atherosclerotic plaques in men and patients older than 65 years. Although similarly prevalent in both sexes, noncalcified and low-attenuation plaques exhibit a better prognostic value in women.
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Affiliation(s)
- Martyna Faber
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Albrecht Will
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Eva Hendrich
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Stefan Martinoff
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Martin Hadamitzky
- Institut für Radiologie und Nuklearmedizin, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstraße 36, 80636, Munich, Germany.
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Long-Term Prognostic Role of Computed Tomography Coronary Angiography for Stable Angina. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [PMCID: PMC7363674 DOI: 10.1007/s11936-020-00818-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of review Chest pain is a common presentation, and there are a wide variety of ways in which it can be investigated and treated. There is growing interest in whether the way we reach a diagnosis of angina can affect the long-term prognosis. In addition to its unparalleled negative predictive value, computed tomography coronary angiography (CCTA) gives anatomical information on the extent and severity of coronary artery disease. This article discusses recent research into the ability of CCTA to predict and improve long-term prognosis for patients with stable angina. Recent findings Results from retrospective studies, randomised controlled trials and meta-analyses all suggest that initial investigation with computed tomography coronary angiography confers a prognostic benefit. In addition, the most recent studies have shown that the assessment of plaque burden and plaque constituents is predictive of long-term outcomes. Summary Management of stable chest pain should be guided by a CCTA-based approach. Future research should focus on whether incorporating plaque analysis strategies into clinical practice confers additional benefit.
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Assessment and management of coronary artery disease in patients undergoing transcatheter aortic valve replacement. Curr Opin Cardiol 2020; 35:540-547. [PMID: 32649355 DOI: 10.1097/hco.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors. RECENT FINDINGS Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason. SUMMARY Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.
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Qiao HY, Tang CX, Schoepf UJ, Tesche C, Bayer RR, Giovagnoli DA, Todd Hudson H, Zhou CS, Yan J, Lu MJ, Zhou F, Lu GM, Jiang JW, Zhang LJ. Impact of machine learning–based coronary computed tomography angiography fractional flow reserve on treatment decisions and clinical outcomes in patients with suspected coronary artery disease. Eur Radiol 2020; 30:5841-5851. [DOI: 10.1007/s00330-020-06964-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/02/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022]
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Senoner T, Plank F, Barbieri F, Beyer C, Birkl K, Widmann G, Adukauskaite A, Friedrich G, Dichtl W, Feuchtner GM. Added value of high-risk plaque criteria by coronary CTA for prediction of long-term outcomes. Atherosclerosis 2020; 300:26-33. [DOI: 10.1016/j.atherosclerosis.2020.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 11/30/2022]
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Shaw LJ, Chandrashekhar Y. Focused Issue on Computed Tomography. JACC Cardiovasc Imaging 2020; 12:1405-1406. [PMID: 31272675 DOI: 10.1016/j.jcmg.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rodriguez-Granillo GA, Nieman K, Carrascosa P, Campisi R, Ambrose JA. Anatomic or functional testing in stable patients with suspected CAD: contemporary role of cardiac CT in the ISCHEMIA trial era. Int J Cardiovasc Imaging 2020; 36:1351-1362. [PMID: 32180079 DOI: 10.1007/s10554-020-01815-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/07/2020] [Indexed: 11/30/2022]
Abstract
One of the foundations of the management of patients with suspected coronary artery disease (CAD) is to avoid unnecessary invasive coronary angiography (ICA) referrals. However, the diagnostic yield of ICA following abnormal conventional stress testing is low. The ability of ischemia testing to predict subsequent myocardial infarction and death is currently being challenged, and more than half of cardiac events among stable patients with suspected CAD occur in those with normal functional tests. The optimal management of patients with stable CAD remains controversial and ischemia-driven interventions, though improving anginal symptoms, have failed to reduce the risk of hard cardiovascular events. In this context, there is an ongoing debate whether the initial diagnostic test among patients with stable suspected CAD should be a functional test or coronary computed tomography angiography. Aside from considering the specific characteristics of individual patients and local availability and conditions, the choice of the initial test relates to whether the objective concerns its role as gatekeeper for ICA, prognosis, or treatment decision-making. Therefore, the aim of this review is to provide a contemporary overview of these issues and discuss the emerging role of CCTA as the upfront imaging tool for most patients with suspected CAD.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, Instituto Medico Eneri, Clinica La Sagrada Familia, Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina. .,Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina.
| | - Koen Nieman
- Stanford University School of Medicine, Cardiovascular Institute, Stanford, CA, USA
| | - Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnostico Maipu, Buenos Aires, Argentina
| | - Roxana Campisi
- Department of Nuclear Medicine, Diagnostico Maipu, Buenos Aires, Argentina
| | - John A Ambrose
- Division of Cardiology, Department of Internal Medicine, University of California San Francisco-Fresno, Fresno, USA
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Weir-McCall JR, Fairbairn TA. Fractional Flow Reserve Derived from CT: The State of Play in 2020. Radiol Cardiothorac Imaging 2020; 2:e190153. [PMID: 33778538 PMCID: PMC7977733 DOI: 10.1148/ryct.2019190153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 06/12/2023]
Abstract
Fractional flow reserve derived from CT is a rapidly developing technique, with an increasing burden of literature supporting its potential role in the workup of patients suspected of having coronary artery disease.
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Affiliation(s)
- Jonathan R. Weir-McCall
- From the Department of Radiology, University of Cambridge School of Clinical Medicine, Box 219, Level 5, Biomedical Campus, Cambridge CB2 0QQ, England (J.R.W.); Royal Papworth Hospital, Cambridge, England (J.R.W.); and Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, England (T.A.F.)
| | - Timothy A. Fairbairn
- From the Department of Radiology, University of Cambridge School of Clinical Medicine, Box 219, Level 5, Biomedical Campus, Cambridge CB2 0QQ, England (J.R.W.); Royal Papworth Hospital, Cambridge, England (J.R.W.); and Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, England (T.A.F.)
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Setting the Standard for Prognostic Analysis. JACC Cardiovasc Imaging 2019; 12:1339-1340. [DOI: 10.1016/j.jcmg.2018.08.006] [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: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 11/18/2022]
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