1
|
Padang R, Pellikka PA. The role of stress echocardiography in the evaluation of coronary artery disease and myocardial ischemia in women. J Nucl Cardiol 2016; 23:1023-1035. [PMID: 27457525 DOI: 10.1007/s12350-016-0592-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/08/2016] [Indexed: 01/06/2023]
Abstract
Considering the unfavorable prognosis of women with ischemic heart disease, an aggressive but safe approach to evaluate women presenting with chest pain is warranted so that coronary artery disease (CAD) can be identified and treated early. Stress echocardiography (SE) has matured into an invaluable technique for the noninvasive detection of obstructive epicardial CAD. Its versatility, accuracy, safety, noninvasiveness, and lack of radiation exposure make SE an attractive technique to apply to the assessment of women with known or suspected heart disease. This article focuses on the current evidence supporting the role of SE in the assessment of CAD and myocardial ischemia in women.
Collapse
Affiliation(s)
- Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| |
Collapse
|
2
|
van Waardhuizen CN, Khanji MY, Genders TS, Ferket BS, Fleischmann KE, Hunink MM, Petersen SE. Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:245-260. [DOI: 10.1093/ehjqcco/qcw029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023]
|
3
|
Incremental value of adenosine stress cardiac magnetic resonance in coronary artery disease detection. Int J Cardiol 2013; 168:4160-7. [DOI: 10.1016/j.ijcard.2013.07.114] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 05/31/2013] [Accepted: 07/13/2013] [Indexed: 01/06/2023]
|
4
|
McBride CB, Cheezum MK, Gore RS, Pathirana IN, Slim AM, Villines TC. Coronary Artery Calcium Testing in Symptomatic Patients: An Issue of Diagnostic Efficiency. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013; 6:211-220. [PMID: 23795234 PMCID: PMC3683145 DOI: 10.1007/s12410-013-9198-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The detection and quantification of coronary artery calcification (CAC) significantly improves cardiovascular risk prediction in asymptomatic patients. Many have advocated for expanded CAC testing in symptomatic patients based on data demonstrating that the absence of quantifiable CAC in patients with possible angina makes obstructive coronary artery disease (CAD) and subsequent adverse events highly unlikely. However, the widespread use of CAC testing in symptomatic patients may be limited by the high background prevalence of CAC and its low specificity for obstructive CAD, necessitating additional testing ('test layering') in a large percentage of eligible patients. Further, adequately powered prospective studies validating the comparative effectiveness of a 'CAC first' approach with regards to cost, safety, accuracy and clinical outcomes are lacking. Due to marked reductions in patient radiation exposure and higher comparative accuracy and prognostic value make coronary computed tomographic angiography the preferred CT-based test for appropriately selected symptomatic patients.
Collapse
Affiliation(s)
- Chad B McBride
- Cardiology Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue., Bethesda, MD 20850 USA
| | | | | | | | | | | |
Collapse
|
5
|
Shaw LJ. Cost-effectiveness and future implications for cardiovascular imaging. Can J Cardiol 2013; 29:350-7. [PMID: 23332968 DOI: 10.1016/j.cjca.2012.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/19/2012] [Accepted: 10/19/2012] [Indexed: 10/27/2022] Open
Abstract
This review highlights the current economic climate for health care and the evidentiary standards that are increasingly applied to appropriate use of cardiovascular imaging. Additionally, the evidence on cost efficiency and effectiveness is explored in this review. Ongoing multicentre registries and clinical trials will further enrich this evidence base with regard to value-based imaging strategies that provide enhanced effectiveness and efficiency resulting in improved patient outcomes.
Collapse
Affiliation(s)
- Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia 30324, USA.
| |
Collapse
|
6
|
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.07.012] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
7
|
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1233] [Impact Index Per Article: 102.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
8
|
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
9
|
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:3097-137. [PMID: 23166210 DOI: 10.1161/cir.0b013e3182776f83] [Citation(s) in RCA: 276] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
10
|
Cortigiani L, Rigo F, Gherardi S, Galderisi M, Bovenzi F, Picano E, Sicari R. Prognostic effect of coronary flow reserve in women versus men with chest pain syndrome and normal dipyridamole stress echocardiography. Am J Cardiol 2011; 106:1703-8. [PMID: 21126613 DOI: 10.1016/j.amjcard.2010.08.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 08/11/2010] [Accepted: 08/11/2010] [Indexed: 02/06/2023]
Abstract
The aim of this study was to investigate the prognostic effect of coronary flow reserve (CFR) on left anterior descending artery (LAD) in women and men with chest pain of unknown origin and normal stress echocardiogram. The study population consisted of 1,660 patients (906 women, 754 men) with chest pain syndrome, no wall motion abnormality on echocardiogram at rest, and dipyridamole (up to 0.84 mg/kg over 6 minutes) stress echocardiogram negative for wall motion criteria. All had undergone stress echocardiography with combined evaluation of CFR on LAD by Doppler. A CFR value ≤2.0 was considered abnormal. Median duration of follow-up was 19 months (interquartile range 10 to 34). Abnormal CFR was assessed in 171 women (19%) and 147 men (19%, p = 0.80). During follow-up, 80 events (20 deaths, 13 ST-elevation myocardial infarctions, and 47 non-ST-elevation myocardial infarctions) occurred. In addition, 128 patients underwent revascularization and were censored. CFR ≤2.0 on LAD was independently associated with prognosis in women (hazard ratio [HR] 16.48, 95% confidence interval [CI] 7.17 to 37.85, p <0.0001) and in men (HR 6.23, 95% CI 3.42 to 11.33, p <0.0001). Antianginal therapy at time of testing (HR 2.11, 95% CI 1.14 to 3.90, p = 0.02) was also a multivariable prognostic predictor in men. Four-year event rate associated with CFR values ≤2.0 and >2.0 were, respectively, 27% and 2% in women (p <0.0001) and 42% and 8% in men (p <0.0001). In conclusion, decreased CFR on LAD is associated with markedly increased risk in women and men with chest pain syndrome and a normal result of dipyridamole stress echocardiography. Conversely, preserved CFR on LAD predicts excellent survival, particularly in women.
Collapse
|
11
|
Bedetti G, Pasanisi EM, Pizzi C, Turchetti G, Loré C. Economic analysis including long-term risks and costs of alternative diagnostic strategies to evaluate patients with chest pain. Cardiovasc Ultrasound 2008; 6:21. [PMID: 18510723 PMCID: PMC2435520 DOI: 10.1186/1476-7120-6-21] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 05/29/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosis costs for cardiovascular disease waste a large amount of healthcare resources. The aim of the study is to evaluate the clinical and economic outcomes of alternative diagnostic strategies in low risk chest pain patients. METHODS We evaluated direct and indirect downstream costs of 6 strategies: coronary angiography (CA) after positive troponin I or T (cTn-I or cTnT) (strategy 1); after positive exercise electrocardiography (ex-ECG) (strategy 2); after positive exercise echocardiography (ex-Echo) (strategy 3); after positive pharmacologic stress echocardiography (PhSE) (strategy 4); after positive myocardial exercise stress single-photon emission computed tomography with technetium Tc 99m sestamibi (ex-SPECT-Tc) (strategy 5) and direct CA (strategy 6). RESULTS The predictive accuracy in correctly identifying the patients was 83,1% for cTn-I, 87% for cTn-T, 85,1% for ex-ECG, 93,4% for ex-Echo, 98,5% for PhSE, 89,4% for ex-SPECT-Tc and 18,7% for CA. The cost per patient correctly identified results $2.051 for cTn-I, $2.086 for cTn-T, $1.890 for ex-ECG, $803 for ex-Echo, $533 for PhSE, $1.521 for ex-SPECT-Tc ($1.634 including cost of extra risk of cancer) and $29.673 for CA ($29.999 including cost of extra risk of cancer). The average relative cost-effectiveness of cardiac imaging compared with the PhSE equal to 1 (as a cost comparator), the relative cost of ex-Echo is 1.5x, of a ex-SPECT-Tc is 3.1x, of a ex-ECG is 3.5x, of cTnI is x3.8, of cTnT is x3.9 and of a CA is 56.3x. CONCLUSION Stress echocardiography based strategies are cost-effective versus alternative imaging strategies and the risk and cost of radiation exposure is void.
Collapse
Affiliation(s)
| | | | | | | | - Cosimo Loré
- Institute of Legal Medicine, University of Siena, Italy
| |
Collapse
|
12
|
Nucifora G, Badano LP, Sarraf-Zadegan N, Karavidas A, Trocino G, Scaffidi G, Pettinati G, Astarita C, Vysniauskas V, Gregori D, Ilerigelen B, Marinigh R, Fioretti PM. Comparison of early dobutamine stress echocardiography and exercise electrocardiographic testing for management of patients presenting to the emergency department with chest pain. Am J Cardiol 2007; 100:1068-73. [PMID: 17884363 DOI: 10.1016/j.amjcard.2007.05.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 05/08/2007] [Accepted: 05/08/2007] [Indexed: 11/22/2022]
Abstract
This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.
Collapse
|
13
|
Conti A, Pieralli F, Sammicheli L, Antoniucci D, Del Bene R, Barletta G. Myocardial infarction redefined: impact on case-load and outcome of patients with suspected acute coronary syndrome and nondiagnostic ECG at presentation. Int J Cardiol 2006; 111:195-201. [PMID: 16085326 DOI: 10.1016/j.ijcard.2005.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2005] [Revised: 06/08/2005] [Accepted: 06/18/2005] [Indexed: 11/27/2022]
Abstract
Risk stratification of chest pain (CP) is still debated. Objective of this study was to evaluate the performance of a risk stratification model for patients with suspected acute coronary syndrome (ACS) and nondiagnostic ECG at presentation, in whom the occurrence of myocardial infarction was either diagnosed following traditional (t-MI) or the recently redefined (r-MI) criteria. First-line 6-h work-up categorized 3068 patients with suspected ACS and nondiagnostic ECG into low-risk for short-term coronary events, intermediate-risk who entered second-line work-up, and high-risk. Intermediate-risk patients with positive second-line work-up and high-risk patients were considered for urgent coronary angiography. Angina, non-fatal MI, sudden death, and revascularization constituted composite end-point (CE) for in-hospital and 6-month outcome. ACS incidence was 16%; r-MI increased by 62% the diagnosis of MI over t-MI. Among 2024 discharged low-risk patients, 12 (0.6%) had non-fatal CE at 6 months. ACS was diagnosed in 19% of 503 intermediate-risk and 96% of 389 high-risk patients. Among ACS patients, in-hospital CE occurred in 14% of t-MI, 7% of r-MI, and 9% of unstable angina (UA) patients (t-MI vs. r-MI and t-MI vs. UA: p<0.05, for both); 6-month CE occurred in 23%, 16% and 12% of t-MI, r-MI and UA, respectively (t-MI vs. UA: p<005). Sensitivity, specificity and accuracy were high both for diagnostic (97%, 98%, 99%, respectively) and treatment (83%, 98%, 97%, respectively) strategy. Risk stratification, and categorization according to traditional or redefined MI and UA criteria allow safe allocation of resources in CP patients with suspected ACS and nondiagnostic ECG at presentation because outcome is accurately predicted.
Collapse
Affiliation(s)
- Alberto Conti
- Emergency Medicine Department, Chest Pain Unit, Azienda Ospedaliero, Universitaria Careggi, Florence, Italy.
| | | | | | | | | | | |
Collapse
|