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Alonso M, Neicheril RK, Shettigar S, Lavina A, Seijo de Armas Y, Carter A, Liang H, Alonso A, Piotrkowski JS. Efficacy of Coronary Computed Tomography Angiography Versus Nuclear Perfusion Stress in Preventing Downstream Imaging and Prolonged Inpatient Length of Stay in Low to Medium Risk Patients With Chest Pain. Cureus 2022; 14:e27326. [PMID: 36042990 PMCID: PMC9411707 DOI: 10.7759/cureus.27326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background The first-line imaging for low to medium-risk patients presenting to the emergency department with stable chest pain is often a matter of debate. Chest pain is the second most common presentation to the emergency department. Non-invasive imaging has been useful in assisting in the diagnosis of coronary artery disease. Aim The aim of this study is to compare outcomes of Single Photon Emission Computed Tomography (SPECT) Nuclear Perfusion Stress and Coronary Computed Tomography Angiography (CCTA) performed in low to medium-risk patients and how they led to prolonged hospitalization and downstream testing. Materials and methods A total of 519 patients were selected for chart review using the following criteria: admitted for chest pain and older than 18 years of age. Those who presented with STEMI (ST-Elevation Myocardial Infarction) or non-(N)STEMI were excluded. Among these patients, four patients were excluded since their initial test was neither a CCTA nor SPECT Nuclear (NM) Perfusion Stress test. Another 30 patients were excluded based on HEART score (a clinical tool to stratify the risk of major adverse cardiac events) >7 and 111 patients with estimated glomerular filtration rate (eGFR) <60 were excluded. A total of 374 patients underwent analysis. Results Univariate data analysis of 374 patients demonstrated a higher percentage of patients with HEART scores 0-3 underwent CCTA (51.6% vs. 31.8% p=0.0250) when compared to patients with SPECT NM perfusion. Multivariable logistic regression revealed that the difference in length of stay between SPECT NM perfusion stress and CCTA was significant, patients with the CCTA test were less likely to have a length of stay ≥24 hours (odds ratio {OR}=0.41, p=0.0465) compared to patients with NM perfusion stress test. Conclusion This retrospective cohort study demonstrated that patients who underwent CCTA upon chest pain admission were more likely to have a decreased length of stay time to less than 24 hours.
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Haase R, Schlattmann P, Gueret P, Andreini D, Pontone G, Alkadhi H, Hausleiter J, Garcia MJ, Leschka S, Meijboom WB, Zimmermann E, Gerber B, Schoepf UJ, Shabestari AA, Nørgaard BL, Meijs MFL, Sato A, Ovrehus KA, Diederichsen ACP, Jenkins SMM, Knuuti J, Hamdan A, Halvorsen BA, Mendoza-Rodriguez V, Rochitte CE, Rixe J, Wan YL, Langer C, Bettencourt N, Martuscelli E, Ghostine S, Buechel RR, Nikolaou K, Mickley H, Yang L, Zhang Z, Chen MY, Halon DA, Rief M, Sun K, Hirt-Moch B, Niinuma H, Marcus RP, Muraglia S, Jakamy R, Chow BJ, Kaufmann PA, Tardif JC, Nomura C, Kofoed KF, Laissy JP, Arbab-Zadeh A, Kitagawa K, Laham R, Jinzaki M, Hoe J, Rybicki FJ, Scholte A, Paul N, Tan SY, Yoshioka K, Röhle R, Schuetz GM, Schueler S, Coenen MH, Wieske V, Achenbach S, Budoff MJ, Laule M, Newby DE, Dewey M. Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data. BMJ 2019; 365:l1945. [PMID: 31189617 PMCID: PMC6561308 DOI: 10.1136/bmj.l1945] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. DESIGN Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. DATA SOURCES Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. RESULTS Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). CONCLUSIONS In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42012002780.
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Affiliation(s)
- Robert Haase
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Data Science, University Hospital of Friedrich Schiller University Jena, Jena, Germany
| | - Pascal Gueret
- Department of Cardiology, Henri Mondor Hospital, University Paris Est Créteil, Créteil, France
| | - Daniele Andreini
- Department of Cardiology and Radiology, Centro Cardiologico Monzino IRCCS, University of Milan, Milan, Italy
| | | | - Hatem Alkadhi
- Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Mario J Garcia
- Department of Cardiology, Montefiore, University Hospital for the Albert Einstein College of Medicine, NY, USA
| | - Sebastian Leschka
- Department of Radiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Willem B Meijboom
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Elke Zimmermann
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Bernhard Gerber
- Department of Cardiology, Clinique Universitaire St Luc, Institut de Recherche Clinique et Expérimentale, Brussels, Belgium
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Abbas A Shabestari
- Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus Universtity Hostipal, Aarhus, Denmark
| | - Matthijs F L Meijs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | - Axel C P Diederichsen
- Department of Cardiology, Glasgow Royal Infirmary and Stobhill Hospital, Glasgow, UK
| | - Shona M M Jenkins
- Department of Cardiology, Glasgow Royal Infirmary and Stobhill Hospital, Glasgow, UK
| | - Juhani Knuuti
- Turku University Hospital and University of Turku, Turku, Finland
| | - Ashraf Hamdan
- Department of Cardiovascular Imaging, Department of Cardiology, Rabin Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Carlos E Rochitte
- Heart Institute, InCor, University of São Paulo Medical School, São Paulo, Brazil
| | - Johannes Rixe
- Department of Cardiology, Kerckhoff Heart Centre, Bad Nauheim, Germany
| | - Yung Liang Wan
- Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital at Linkou, Taoyaun City, Taiwan
| | - Christoph Langer
- Heart and Diabetes Center NRW in Bad Oeynhausen, University Clinic of the Ruhr-University Bochum, Bochum, Germany
| | - Nuno Bettencourt
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | - Eugenio Martuscelli
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Said Ghostine
- Department of Cardiology, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Lin Yang
- Department of Radiology, Beijing Anzhen Hospital, Beijing, China
| | - Zhaqoi Zhang
- Department of Radiology, Beijing Anzhen Hospital, Beijing, China
| | - Marcus Y Chen
- National Heart and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - David A Halon
- Cardiovascular Clinical Research Unit, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Matthias Rief
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Kai Sun
- Department of Radiology, Baotou Central Hospital, Inner Mongolia Province, China
| | - Beatrice Hirt-Moch
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | | | - Roy P Marcus
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Réda Jakamy
- Department of Cardiology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Benjamin J Chow
- University of Ottawa, Heart Institute, Ottawa, Ontario, Canada
| | - Philipp A Kaufmann
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | | | | | - Klaus F Kofoed
- The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jean-Pierre Laissy
- Department of Diagnostic Imaging and Interventional Radiology, Bichat University Hospital, Paris, France
| | - Armin Arbab-Zadeh
- Division of Cardiology, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD, USA
| | | | - Roger Laham
- BIDMC/Harvard Medical School, Department of Cardiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | | | - John Hoe
- Department of Radiology, Mount Elizabeth Hospital, Singapore
| | - Frank J Rybicki
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Arthur Scholte
- Department of Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Narinder Paul
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Swee Y Tan
- National Heart Centre, Singapore, Singapore
| | | | - Robert Röhle
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg M Schuetz
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sabine Schueler
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Maria H Coenen
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Viktoria Wieske
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | | | - Michael Laule
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - David E Newby
- British Heart Foundation, University of Edinburgh, Edinburgh, UK
| | - Marc Dewey
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Kim YJ, Yong HS, Kim SM, Kim JA, Yang DH, Hong YJ. Korean guidelines for the appropriate use of cardiac CT. Korean J Radiol 2015; 16:251-85. [PMID: 25741189 PMCID: PMC4347263 DOI: 10.3348/kjr.2015.16.2.251] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 01/03/2015] [Indexed: 01/07/2023] Open
Abstract
The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
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Affiliation(s)
- Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul 152-703, Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Jeong A Kim
- Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 411-706, Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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Bruckel JT, Larsen G, Benson MR. Obese sedentary patients with dyspnoea on exertion who are at low risk for coronary artery disease by clinical criteria have a very low prevalence of coronary artery disease. Clin Obes 2014; 4:143-9. [PMID: 25826769 DOI: 10.1111/cob.12053] [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: 12/08/2013] [Revised: 02/12/2014] [Accepted: 02/27/2014] [Indexed: 11/30/2022]
Abstract
Dyspnoea, a much less specific symptom of ischaemia than chest discomfort, is common among obese patients. Patients with dyspnoea often undergo stress testing as part of their evaluation. We sought to examine the yield of stress testing in non-elderly, obese, sedentary patients with dyspnoea on exertion (DOE) as a chief complaint.We reviewed stress echocardiograms carried out on 203 patients in a stress testing laboratory at a major tertiary care centre. Of these, 81 (40%) fell into a group that was at low risk for coronary artery disease (CAD) by clinical criteria. Ischaemia was detected in two patients in the low-risk group (2.5%), and these results were likely false positives. In the higher risk group, 9.0% of functional tests showed ischaemia; after further testing, 2.5% of the higher risk patients were found to have obstructive coronary lesions. Clinical follow-up was performed for a mean of 815 days. New obstructive coronary disease was detected in 1.6% of all patients, and these patients were from the higher risk group. In obese sedentary patients with DOE but otherwise at low risk of coronary disease stress testing is of very low yield. DOE is generally not an anginal equivalent in this patient population.
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Affiliation(s)
- J T Bruckel
- Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Advances in genomics and proteomics promise to transform biomarker research, in which the major challenges will not be the discovery of new markers but rather the optimal selection and validation of a subgroup of clinically useful markers from the large pool of candidates. Critically, the value of new biomarkers panels will need to be assessed in the context of readily available clinical information in order to create more actionable knowledge rather than just greater complexity. Appropriate methodologies for the clinical and statistical evaluation of so called "multi-marker strategies" have not been systematically defined. Although specific criteria for the appropriate clinical and statistical evaluation of multi-marker strategies will vary based on the intended use (e.g., diagnosis vs. screening), the ultimate measure of success is the ability for a biomarker panel to both correct a meaningful portion of misclassification by standard methods (discrimination) and to improve quantification of absolute risk (calibration) in comparison to existing clinical information. Findings should be validated in an independent dataset of the representative patient population before a given multi-marker strategy can be considered for clinical use. Here, we define multi-marker strategies, summarize recent examples of biomarker combinations in heart failure, address key statistical and clinical issues, and discuss future directions for this rapidly evolving field.
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Abstract
Biomarkers are becoming increasingly available for clinical use, particularly in the care of patients with heart failure. For health care providers, a major difficulty is how to interpret and apply these increasing amounts of diagnostic and prognostic information. Consequently, the scientific challenge is evolving from the discovery of biomarkers to the selection and validation of select panels of clinically useful markers that balance performance and practicality. Optimal combinations of biomarkers will vary based on the intended use (eg, diagnosis vs prognosis). The final goal must be to generate more actionable knowledge that improves patient management and outcomes, rather than merely creating greater complexity. Here we conceptually define multiple biomarker strategies, provide examples of emerging biomarker panels used in the care of patients with heart failure, and address key statistical and clinical issues for this rapidly evolving field.
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Affiliation(s)
- Larry A Allen
- Division of Cardiology, Colorado Cardiovascular Outcomes Research Consortium and Section of Heart Failure and Cardiac Transplantation, University of Colorado Denver, Aurora, CO 80045, USA.
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Rozanski A, Gransar H, Shaw L, Wong ND, Min J, Miranda-Peats R, Hayes SW, Friedman JD, Berman DS. Comparison of the atherosclerotic burden among asymptomatic patients vs matched volunteers. J Nucl Cardiol 2011; 18:291-8. [PMID: 21184209 PMCID: PMC3069310 DOI: 10.1007/s12350-010-9324-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 11/20/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND While asymptomatic patients should have a lower risk of cardiac events compared to symptomatic patients referred for cardiac stress testing, comparable event rates have been noted in some prior prognostic studies. To test if a high burden of undetected atherosclerosis among asymptomatic patients helps explain such findings, we compared atherosclerotic burden, as measured by coronary artery calcium (CAC) scanning, in propensity-matched groups of volunteers and asymptomatic patients. METHODS CAC scans were performed on a research basis in 136 asymptomatic patients referred for exercise myocardial perfusion SPECT and in 1,398 volunteers. We performed matching by propensity scores to compare volunteers with the same CAD risk factor profile as our asymptomatic patients. RESULTS Among our matched groups, asymptomatic patients had significantly greater mean CAC scores than volunteers (394 ± 805 vs 151 ± 349, P = .001), primarily due to a higher frequency of CAC scores >1,000 (15.4% vs 2.5%, P < .001). Inducible myocardial ischemia by SPECT was present in 7% of patients, but was selectively concentrated among those with CAC scores >1,000, occurring in 27.0% of such patients vs only 1.9% among patients with CAC scores <1,000 (P < .0001). CONCLUSIONS In contrast to asymptomatic volunteers, asymptomatic patients referred for cardiac stress testing possess more extensive atherosclerosis as measured by CAC. Among asymptomatic patients with high CAC scores, the frequency of concomitant inducible myocardial ischemia is high. These results help explain prior prognostic studies concerning asymptomatic patients and indicate the importance of making a clinical distinction between healthy subjects and asymptomatic patients with respect to atherosclerotic risk.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology, St. Lukes Roosevelt Hospital, 1111 Amsterdam Avenue, New York, NY 10025 USA
| | - Heidi Gransar
- The Departments of Imaging and Medicine and the Burns and Allen Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Building, Room 1258, Los Angeles, CA 90048 USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - Leslee Shaw
- Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Nathan D. Wong
- The Heart Disease Prevention Program, University of California, Irvine, CA USA
| | - James Min
- Departments of Medicine and Radiology, Weill Medical College of Cornell University and New York Presbyterian Hospital, New York, NY USA
| | - Romalisa Miranda-Peats
- The Departments of Imaging and Medicine and the Burns and Allen Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Building, Room 1258, Los Angeles, CA 90048 USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - Sean W. Hayes
- The Departments of Imaging and Medicine and the Burns and Allen Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Building, Room 1258, Los Angeles, CA 90048 USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - John D. Friedman
- The Departments of Imaging and Medicine and the Burns and Allen Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Building, Room 1258, Los Angeles, CA 90048 USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - Daniel S. Berman
- The Departments of Imaging and Medicine and the Burns and Allen Research Institute, Cedars-Sinai Medical Center, 8700 Beverly Building, Room 1258, Los Angeles, CA 90048 USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA USA
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Chatziioannou SN, Moore WH, Dhekne RD, Ford PV. Women with high exercise tolerance and the role of myocardial perfusion imaging. Clin Cardiol 2009; 24:475-80. [PMID: 11403510 PMCID: PMC6655181 DOI: 10.1002/clc.4960240611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Myocardial perfusion imaging (MPI) provides incremental diagnostic and prognostic information, even in patients with high exercise tolerance. HYPOTHESIS Myocardial perfusion imaging provides significant diagnostic value, specifically in women with high exercise tolerance. METHODS Our study population consisted of all women who underwent exercise MPI in our Department from January 1992 to June 1996 and reached at least Stage IV in the Bruce protocol. Patients were divided into those with known and those with possible coronary artery disease (CAD). All patients were followed for 3 years from the performance of MPI. RESULTS Of 4,803 women who underwent myocardial perfusion imaging, 3,183 had exercise stressing, and of those, 311 reached at least Stage IV in the Bruce protocol. Of these 311 MPI scans, only 23 (7.4%) were abnormal (reversible, fixed, or mixed) and the remaining 288 (92.6%) were normal. Of the 82 patients with known CAD, 13 (15.8%) had an abnormal MPI, while only 10 (4.4%) of the 229 patients with possible CAD. No myocardial infarction or cardiac death occurred within 3 years; one patient with normal MPI needed revascularization. CONCLUSION In women with high exercise tolerance, especially in those without already known CAD, the yield of MPI is very low. Women with high exercise tolerance have an excellent prognosis.
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Affiliation(s)
- S N Chatziioannou
- Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
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Alvarez-Llamas G, de la Cuesta F, Barderas MEG, Darde V, Padial LR, Vivanco F. Recent advances in atherosclerosis-based proteomics: new biomarkers and a future perspective. Expert Rev Proteomics 2009; 5:679-91. [PMID: 18937558 DOI: 10.1586/14789450.5.5.679] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vascular proteomics is providing two main types of data: proteins that actively participate in vascular pathophysiological processes and novel protein candidates that can potentially serve as useful clinical biomarkers. Although both types of proteins can be identified by similar proteomic strategies and methods, it is important to clearly distinguish biomarkers from mediators of disease. A particular protein, or group of proteins, may participate in a pathogenic process but not serve as an effective biomarker. Alternatively, a useful biomarker may not mediate pathogenic pathways associated with disease (i.e., C-reactive protein). To date, there are no clear successful examples in which discovery proteomics has led to a novel useful clinical biomarker in cardiovascular diseases. Nevertheless, new sources of biomarkers are being explored (i.e., secretomes, circulating cells, exosomes and microparticles), an increasing number of novel proteins involved in atherogenesis are constantly described, and new technologies and analytical strategies (i.e., quantitative proteomics) are being developed to access low abundant proteins. Therefore, this presages a new era of discovery and a further step in the practical application to diagnosis, prognosis and early action by medical treatment of cardiovascular diseases.
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Vivanco F, Padial L, Darde V, de la Cuesta F, Alvarez-Llamas G, Diaz-Prieto N, Barderas M. Proteomic Biomarkers of Atherosclerosis. Biomark Insights 2008; 3:101-113. [PMID: 19578499 PMCID: PMC2688368 DOI: 10.4137/bmi.s488] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
SUMMARY: Biomarkers provide a powerful approach to understanding the spectrum of cardiovascular diseases. They have application in screening, diagnostic, prognostication, prediction of recurrences and monitoring of therapy. The "omics" tool are becoming very useful in the development of new biomarkers in cardiovascular diseases. Among them, proteomics is especially fitted to look for new proteins in health and disease and is playing a significant role in the development of new diagnostic tools in cardiovascular diagnosis and prognosis. This review provides an overview of progress in applying proteomics to atherosclerosis. First, we describe novel proteins identified analysing atherosclerotic plaques directly. Careful analysis of proteins within the atherosclerotic vascular tissue can provide a repertoire of proteins involved in vascular remodelling and atherogenesis. Second, we discuss recent data concerning proteins secreted by atherosclerotic plaques. The definition of the atheroma plaque secretome resides in that proteins secreted by arteries can be very good candidates of novel biomarkers. Finally we describe proteins that have been differentially expressed (versus controls) by individual cells which constitute atheroma plaques (endothelial cells, vascular smooth muscle cells, macrophages and foam cells) as well as by circulating cells (monocytes, platelets) or novel biomarkers present in plasma.
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Affiliation(s)
- F. Vivanco
- Department of Immunology. Fundación Jiménez Díaz, Madrid, Spain
- Department of Biochemistry and Molecular Biology I, Universidad Complutense, Proteomic Unit, Madrid, Spain
| | - L.R. Padial
- Department of Cardiology. Hospital Virgen de la Salud, SESCAM, Toledo, Spain
| | - V.M. Darde
- Department of Immunology. Fundación Jiménez Díaz, Madrid, Spain
| | - F. de la Cuesta
- Department of Immunology. Fundación Jiménez Díaz, Madrid, Spain
| | | | - Natacha Diaz-Prieto
- Department of Vascular Pathophysiology. Hospital Nacional de Paraplejicos, SESCAM, Toledo, Spain
| | - M.G. Barderas
- Department of Immunology. Fundación Jiménez Díaz, Madrid, Spain
- Department of Vascular Pathophysiology. Hospital Nacional de Paraplejicos, SESCAM, Toledo, Spain
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Technology Insight: biomarker development in acute kidney injury--what can we anticipate? ACTA ACUST UNITED AC 2008; 4:154-65. [PMID: 18227821 DOI: 10.1038/ncpneph0723] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Accepted: 12/04/2007] [Indexed: 12/17/2022]
Abstract
Early diagnosis has been the 'Achilles heel' of acute kidney injury (AKI) that has prevented successful implementation of treatment strategies. To date, pharmacological intervention has been largely unsuccessful or equivocal, and morbidity and mortality associated with AKI have remained unacceptably high. Despite their well-known limitations, the most widely used biomarkers for the early diagnosis of AKI are serum creatinine, blood urea nitrogen and urine output. Development of new biomarkers is imperative. A variety of methods have been employed to discover new biomarkers of AKI, including transcriptomics, proteomics, gene arrays, lipidomics and imaging technologies. Clinical trials are underway to establish the validity of the biomarkers discovered using these techniques. This Review summarizes the importance of biomarkers of AKI, from their discovery to clinical practice, from the current perspective and that of what to expect in the future. Great strides forward are being made in breaking down important barriers to the successful prevention and treatment of this devastating disorder.
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Rozanski A, Gransar H, Wong ND, Shaw LJ, Miranda-Peats R, Polk D, Hayes SW, Friedman JD, Berman DS. Clinical Outcomes After Both Coronary Calcium Scanning and Exercise Myocardial Perfusion Scintigraphy. J Am Coll Cardiol 2007; 49:1352-61. [PMID: 17394969 DOI: 10.1016/j.jacc.2006.12.035] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 11/22/2006] [Accepted: 12/08/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this work was to assess the prognosis in patients undergoing both coronary artery calcium (CAC) scanning and exercise myocardial perfusion scintigraphy (MPS). BACKGROUND Whereas the prognostic effectiveness of MPS is well established, recent studies indicate that quantification of CAC also predicts cardiac outcomes. However, prognostic information is not yet available upon which to guide the management of patients who have had both tests. METHODS We assessed the frequency of cardiac death and myocardial infarction over a mean follow-up of 32 +/- 16 months in 1,153 patients undergoing both CAC scanning and MPS. Results were compared with those from a referent cohort of 9,308 patients who had earlier undergone MPS only. RESULTS The frequency of myocardial ischemia rose with increasing CAC scores (p < 0.001), but ischemia was present in only 64 patients. Among the 1,089 nonischemic patients, of which only 3 (0.3%) underwent early revascularization, the annualized cardiac event rate was <1% in all CAC subgroups, including those with CAC scores >1,000. Kaplan-Meier analysis revealed similarly low cardiac event rates among nonischemic patients with CAC scores >1,000 and nonischemic patients with Bayesian coronary artery disease likelihood > or =85%. Late myocardial revascularization rates were also similar in these 2 groups. CONCLUSIONS Among patients with nonischemic MPS studies, high CAC scores do not confer an increased risk for cardiac events. Thus, although patients with high CAC scores may be considered for intensive medical therapy to prevent future coronary artery disease events, a normal MPS study in such patients suggests no need for more aggressive interventions.
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Affiliation(s)
- Alan Rozanski
- Department of Medicine, St. Luke's Roosevelt Hospital, New York, New York, USA
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Affiliation(s)
- Ramachandran S Vasan
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Department of Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, MA, USA.
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Suchday S, Krantz DS, Gottdiener JS. Relationship of socioeconomic markers to daily life ischemia and blood pressure reactivity in coronary artery disease patients. Ann Behav Med 2005; 30:74-84. [PMID: 16097908 DOI: 10.1207/s15324796abm3001_9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Socioeconomic status (SES) is an important predictor of clinical outcomes in patients with coronary artery disease (CAD). PURPOSE We hypothesized that a selected sample of low SES cardiac patients would display heightened cardiovascular stress responses in the laboratory and increased daily life ischemia compared to otherwise comparable higher SES patients. METHODS Eighty-two patients (M age=61.8+/-9.4 years; 71 men, 11 women) with a known history of CAD engaged in a stressful mental arithmetic task while blood pressure (BP) measures were collected. Myocardial ischemia was subsequently assessed via 48-hr ambulatory electrocardiographic monitoring in a subgroup of 51 patients. SES was defined by participants' residential block groups, which were linked to Census Bureau data about their neighborhood, including per capita income, percentage of the population below poverty, educational level, as well as self-report of number of years of education. RESULTS Contrary to expectation, high SES participants in the study displayed higher diastolic BP (p<.01) and systolic BP (p<.001) responses to mental stress in the laboratory. CONCLUSIONS Participants with daily life ischemia came from wealthier neighborhoods using indexes of poverty (p<.01), income (p<.02), and education (p<.04) compared to patients without ambulatory ischemia. This relationship was not accounted for by age, sex, race, body mass index, marital status, or measures of disease severity.
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Affiliation(s)
- Sonia Suchday
- Albert Einstein College of Medicine, Department of Clinical Health Psychology, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY 10461, USA.
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Thangaroopan M, Choy JB. Is transesophageal echocardiography overused in the diagnosis of infective endocarditis? Am J Cardiol 2005; 95:295-7. [PMID: 15642576 DOI: 10.1016/j.amjcard.2004.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2004] [Revised: 08/31/2004] [Accepted: 08/31/2004] [Indexed: 10/26/2022]
Abstract
Because of its greater sensitivity, transesophageal echocardiography (TEE) is often misused as a screening tool for the exclusion of infective endocarditis (IE) in patients with small clinical probability of the disease. This study examined the role of using TEE exclusively at a Canadian tertiary care center for the diagnosis of IE and determined which clinical variables are most often associated with positive or negative echocardiographic results supporting or refuting the diagnosis.
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Affiliation(s)
- Molly Thangaroopan
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
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Sierra F, Torres D, Cárdenas A. The role of likelihood ratio in clinical diagnosis: applicability in the setting of spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol 2005; 3:85-9. [PMID: 15645409 DOI: 10.1016/s1542-3565(04)00600-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite imperfect clinical information and uncertainty about clinical course and outcome, the clinician's main task is to make reasonable decisions about patient care. The clinical history and physical examination typically provide information that is useful for making a diagnosis; however, we still rely on laboratory and radiologic tests to confirm a diagnosis in most cases. Understanding the operative characteristic of a test is of key importance because it can change the probability that a patient has a disease before the result of a test is known. This operative characteristic, better known as the likelihood ratio (LR), is a global assessment of the information provided by a test. The LR allows calculating the odds that a patient has a disease after a test is performed. In this article, we explain the meaning of the LR, how it works, and the applicability of this tool in the setting of a challenging scenario in clinical practice, spontaneous bacterial peritonitis.
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Affiliation(s)
- Fernando Sierra
- Division of Gastroenterology and Hepatology, Fundación Santa Fe de Bogotá, Columbia
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18
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Rudusky BM. Clinical logistics in treadmill exercise stress testing. Angiology 2001; 52:729-34. [PMID: 11716324 DOI: 10.1177/000331970105201101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The predictability as to a positive or negative outcome of treadmill exercise stress testing in 341 consecutively studied patients referred for diagnostic purposes is presented. A clinical decision as to the result was derived by asking 2 simple questions and reviewing the pretest ECG. Additional clinical logistics included the type of physician ordering the study, smoking history, symptoms, and basic patient history. The predictable accuracy was 77.7% for the total patient group and 81.5% when the questionable cases (reflecting a neutral or ambivalent cardiologist's opinion) were eliminated.
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Affiliation(s)
- B M Rudusky
- The Northeast Cardiovascular Clinic and Research Institute, Wilkes-Barre, PA, USA
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Berman D, Hachamovitch R, Lewin H, Friedman J, Shaw L, Germano G. Risk stratification in coronary artery disease: implications for stabilization and prevention. Am J Cardiol 1997; 79:10-6. [PMID: 9223352 DOI: 10.1016/s0002-9149(97)00380-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Noninvasive nuclear imaging techniques, including dual-isotope myocardial perfusion single-photon emission computed tomography (SPECT), have been employed in the development of strategies for diagnosis and risk stratification of patients with suspected or known coronary artery disease. These risk-stratification strategies are based on studies in which known outcome has been linked to diagnostic and prognostic information provided by myocardial perfusion SPECT. This article describes a validated dual-isotope exercise protocol for assessment of perfusion and function and reviews the evidence on which a cost-effective risk management strategy is based.
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Affiliation(s)
- D Berman
- Division of Nuclear Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048-1865, USA
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