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Michalowska AM, Zhang W, Shanbhag A, Miller RJ, Lemley M, Ramirez G, Buchwald M, Killekar A, Kavanagh PB, Feher A, Miller EJ, Einstein AJ, Ruddy TD, Liang JX, Builoff V, Ouyang D, Berman DS, Dey D, Slomka PJ. Holistic AI analysis of hybrid cardiac perfusion images for mortality prediction. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.23.24305735. [PMID: 38712025 PMCID: PMC11071553 DOI: 10.1101/2024.04.23.24305735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background While low-dose computed tomography scans are traditionally used for attenuation correction in hybrid myocardial perfusion imaging (MPI), they also contain additional anatomic and pathologic information not utilized in clinical assessment. We seek to uncover the full potential of these scans utilizing a holistic artificial intelligence (AI)-driven image framework for image assessment. Methods Patients with SPECT/CT MPI from 4 REFINE SPECT registry sites were studied. A multi-structure model segmented 33 structures and quantified 15 radiomics features for each on CT attenuation correction (CTAC) scans. Coronary artery calcium and epicardial adipose tissue scores were obtained from separate deep-learning models. Normal standard quantitative MPI features were derived by clinical software. Extreme Gradient Boosting derived all-cause mortality risk scores from SPECT, CT, stress test, and clinical features utilizing a 10-fold cross-validation regimen to separate training from testing data. The performance of the models for the prediction of all-cause mortality was evaluated using area under the receiver-operating characteristic curves (AUCs). Results Of 10,480 patients, 5,745 (54.8%) were male, and median age was 65 (interquartile range [IQR] 57-73) years. During the median follow-up of 2.9 years (1.6-4.0), 651 (6.2%) patients died. The AUC for mortality prediction of the model (combining CTAC, MPI, and clinical data) was 0.80 (95% confidence interval [0.74-0.87]), which was higher than that of an AI CTAC model (0.78 [0.71-0.85]), and AI hybrid model (0.79 [0.72-0.86]) incorporating CTAC and MPI data (p<0.001 for all). Conclusion In patients with normal perfusion, the comprehensive model (0.76 [0.65-0.86]) had significantly better performance than the AI CTAC (0.72 [0.61-0.83]) and AI hybrid (0.73 [0.62-0.84]) models (p<0.001, for all).CTAC significantly enhances AI risk stratification with MPI SPECT/CT beyond its primary role - attenuation correction. A comprehensive multimodality approach can significantly improve mortality prediction compared to MPI information alone in patients undergoing cardiac SPECT/CT.
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Affiliation(s)
- Anna M Michalowska
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Wenhao Zhang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aakash Shanbhag
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Signal and Image Processing Institute, Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, CA, USA
| | - Robert Jh Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiac Sciences, University of Calgary, Calgary AB, Canada
| | - Mark Lemley
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Giselle Ramirez
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mikolaj Buchwald
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aditya Killekar
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Paul B Kavanagh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Attila Feher
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew J Einstein
- Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, New York, United States
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Joanna X Liang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Valerie Builoff
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
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2
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Shah NR, Hulten EA. Listening is still the first 'test' in diagnosing patients with chest pain. J Nucl Cardiol 2024; 31:101772. [PMID: 38262326 DOI: 10.1016/j.nuclcard.2023.101772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Nishant R Shah
- Division of Cardiology, Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.
| | - Edward A Hulten
- Division of Cardiology, Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
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3
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Tamaki N, Manabe O. Current status and perspectives of nuclear cardiology. Ann Nucl Med 2024; 38:20-30. [PMID: 37891375 DOI: 10.1007/s12149-023-01878-1] [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: 08/02/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023]
Abstract
Nuclear cardiology has long been used to identify myocardial ischemia for appropriate treatment strategies for stable coronary artery disease (CAD). After the Ischemia Trial, it is time to reevaluate the significance of ischemia assessment. Functional imaging continues to play pivotal role in detecting microcirculatory disturbances. PET provides a clear image of blood flow distribution and is useful for the quantitative evaluation of myocardial flow reserve (MFR), which plays an important role in predicting treatment strategies and improving prognosis in CAD. Heart failure has become a major area of focus in cardiovascular medicine. Radionuclide imaging has been widely applied in this field. FDG PET is useful in identifying cardiac sarcoidosis and active inflammation. Clinical values of I-123 MIBG and BMIPP SPECT have been reported worldwide from Japan. Additionally, clinical experiences of Tc-99m pyrophosphate imaging have recently gained attention for assessing cardiac amyloidosis. Cardiac PET/CT and PET/MR imaging permit combined assessment of metabolic/functional/structural analyses of various cardiac diseases. While other non-invasive imaging modalities have rapidly been developed, the roles of radionuclide imaging remain to be valuable for early and accurate diagnosis and patient management in most cases of chronic CAD and various cardiovascular diseases.
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Affiliation(s)
- Nagara Tamaki
- Kyoto College of Medical Science, Kyoto, Japan.
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Osamu Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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4
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Patel KK, McGhie AI, Kennedy KF, Thompson RC, Spertus JA, Sperry BW, Shaw LJ, Bateman TM. Impact of Positron Emission Tomographic Myocardial Perfusion Imaging on Patient Selection for Revascularization. J Am Coll Cardiol 2023; 82:1662-1672. [PMID: 37852696 DOI: 10.1016/j.jacc.2023.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Positron emission tomography (PET) myocardial perfusion imaging (MPI) quantifies left ventricular ejection fraction (LVEF) at peak stress. PET LVEF reserve (LVEF-R = stress LVEF - rest LVEF) offers diagnostic and prognostic value. OBJECTIVES The purpose of this study was to determine if PET LVEF-R identifies patients with survival benefit postrevascularization. METHODS We followed 14,649 unique consecutive patients undergoing 82Rb rest/stress PET MPI from January 2010 to January 2016 (excluding known cardiomyopathy). Adjusted Cox models were built to predict all-cause death, and the 3-way interaction of known coronary artery disease (CAD) (prior myocardial infarction/revascularization), LVEF-R, and 90-day revascularization was tested. RESULTS Known CAD was present in 4,982 (34.0%). Ischemia was detected in 5,396 (36.8%; ≥10% in 1,909 [13%]). Mean LVEF-R was 4.2% ± 5.7%, and was ≤0, 1 to 5, and >5 in 3,349 (22.9%), 5,266 (35.9%), and 6,034 (41.2%). Over median follow-up of 3.4 years (IQR: 1.9-5.2 years), 1,324 (8.1%) had 90-day revascularization, and there were 2,192 (15.0%) deaths. In multivariable modeling, there was a significant 3-way interaction among known CAD, LVEF-R, and 90-day revascularization (P = 0.025), such that LVEF-R ≤0 identified patients with survival benefit with 90-day revascularization in those without prior CAD (interaction P = 0.005), independently beyond percent ischemia and myocardial flow reserve. Among patients with known CAD, LVEF-R was not prognostic of death (HR: 0.99; 95% CI: 0.98-1.02; P = 0.98). CONCLUSIONS A lack of augmentation or drop in LVEF with vasodilator stress on PET MPI independently identifies patients who have better survival with revascularization within 90 days post-MPI compared with medical therapy, in absence of prior myocardial infarction or revascularization. Multiparametric assessment of ischemia with PET can optimize post-test management.
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Affiliation(s)
- Krishna K Patel
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA.
| | - A Iain McGhie
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Brett W Sperry
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Timothy M Bateman
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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5
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Faro DC, Laudani C, Agnello FG, Ammirabile N, Finocchiaro S, Legnazzi M, Mauro MS, Mazzone PM, Occhipinti G, Rochira C, Scalia L, Spagnolo M, Greco A, Capodanno D. Complete Percutaneous Coronary Revascularization in Acute Coronary Syndromes With Multivessel Coronary Disease: A Systematic Review. JACC Cardiovasc Interv 2023; 16:2347-2364. [PMID: 37821180 DOI: 10.1016/j.jcin.2023.07.043] [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: 04/02/2023] [Revised: 06/06/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023]
Abstract
Multivessel disease (MVD) affects approximately 50% of patients with acute coronary syndromes (ACS) and is significantly burdened by poor outcomes and high mortality. It represents a clinical challenge in patient management and decision making and subtends an evolving research area related to the pathophysiology of unstable plaques and local or systemic inflammation. The benefits of complete revascularization are established in hemodynamically stable ACS patients with MVD, and guidelines provide some reference points to inform clinical practice, based on an evidence level that is solid for ST-segment elevation myocardial infarction and less robust for non-ST-segment elevation myocardial infarction and cardiogenic shock. However, several areas of uncertainty remain, such as the optimal timing for complete revascularization or the best guiding strategy for intermediate stenoses. We performed a systematic review of current evidence in the field of percutaneous revascularization in ACS and MVD, also including future perspectives from ongoing trials that will directly compare different timing strategies and investigate the role of invasive and noninvasive guidance techniques. (Complete percutaneous coronary revascularization in patients with acute myocardial infarction and multivessel disease; CRD42022383123).
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Affiliation(s)
- Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Federica Giuseppa Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Marco Legnazzi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy.
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6
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Miura S, Okizaki A, Kumamaru H, Manabe O, Naya M, Miyazaki C, Yamashita T. Interaction of impaired myocardial flow reserve and extent of myocardial ischemia assessed using 13N-ammonia positron emission tomography imaging on adverse cardiovascular outcomes. J Nucl Cardiol 2023; 30:2043-2053. [PMID: 37012523 DOI: 10.1007/s12350-023-03255-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 02/14/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Myocardial flow reserve (MFR) and the extent of myocardial ischemia identify patients at high risk of major adverse cardiovascular events (MACEs). Associations between positron emission tomography (PET)-assessed extent of ischemia, MFR, and MACEs is unclear. METHOD Overall, 640 consecutive patients with suspected or known coronary artery disease undergoing 13N-ammonia myocardial perfusion PET were followed-up for MACEs. Patients were categorized into three groups based on myocardial ischemia severity: Group I (n = 335), minimal (myocardial ischemia < 5%); Group II (n = 150), mild (5-10%); and Group III (n = 155), moderate-to-severe (> 10%). RESULTS Cardiovascular death and MACEs occurred in 17 (3%) and 93 (15%) patients, respectively. Following statistical adjustment for confounding factors, impaired MFR (global MFR < 2.0) was revealed as an independent predictor of MACEs in Groups I (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.48-5.64; P = 0.002) and II (HR, 3.40; 95% CI 1.37-8.41; P = 0.008) but was not significant in Group III (HR, 1.15; 95% CI 0.59-2.26; P = 0.67), with a significant interaction (P < 0.0001) between the extent of myocardial ischemia and MFR. CONCLUSION Impaired MFR was significantly associated with increased risk of MACEs in patients with ≤ 10% myocardial ischemia but not with those having > 10% ischemia, allowing a clinically effective risk stratification.
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Affiliation(s)
- Shiro Miura
- Department of Cardiology, Hokkaido Ohno Memorial Hospital, 2-1-16-1 Miyanosawa, Nishi-Ku, Sapporo, 063-0052, Japan.
| | - Atsutaka Okizaki
- Department of Radiology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Manabe
- Department of Radiology, Saitama Medical Center, Jichi Medical University, Saitama-Shi, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido, University Graduate School of Medicine, Sapporo, Japan
| | - Chihoko Miyazaki
- Department of Diagnostic Radiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - Takehiro Yamashita
- Department of Cardiology, Hokkaido Ohno Memorial Hospital, 2-1-16-1 Miyanosawa, Nishi-Ku, Sapporo, 063-0052, Japan
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7
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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8
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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9
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Shah NR, Hulten EA, Tandon S, Murthy VL, Dorbala S, Thompson RC. Recent clinical trials support continued emphasis on patient-first over modality-first approaches to initial test selection in patients with stable ischemic heart disease. J Nucl Cardiol 2023; 30:1739-1744. [PMID: 35149975 DOI: 10.1007/s12350-022-02908-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Nishant R Shah
- Division of Cardiology, Department of Medicine, Brown University Alpert Medical School, 830 Chalkstone Avenue, Providence, RI, 02908, USA.
| | - Edward A Hulten
- Department of Medicine, F. Edward Hebert Medical School Uniformed Services, University of Health Sciences, Bethesda, MD, USA
| | - Suman Tandon
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Venkatesh L Murthy
- Departments of Medicine and Radiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sharmila Dorbala
- Departments of Medicine and Radiology, Harvard Medical School, Boston, MA, USA
| | - Randall C Thompson
- Department of Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, KS, USA
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10
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Hage FG, Einstein AJ, Ananthasubramaniam K, Bourque JM, Case J, DePuey EG, Hendel RC, Henzlova MJ, Shah NR, Abbott BG, Al Jaroudi W, Better N, Doukky R, Duvall WL, Malhotra S, Pagnanelli R, Peix A, Reyes E, Saeed IM, Sanghani RM, Slomka PJ, Thompson RC, Veeranna V, Williams KA, Winchester DE. Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement. J Nucl Cardiol 2023; 30:864-907. [PMID: 36607538 DOI: 10.1007/s12350-022-03162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Fadi G Hage
- Section of Cardiology, Birmingham VA Medical Center, Birmingham, AL, USA.
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 446 GSB, 520 19Th Street South, Birmingham, AL, 35294, USA.
| | - Andrew J Einstein
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine and Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Jamieson M Bourque
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, VA, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - James Case
- Cardiovascular Imaging Technologies, Kansas City, MO, USA
| | - E Gordon DePuey
- Mount Sinai Morningside Hospital, New York, NY, USA
- Bay Ridge Medical Imaging, Brooklyn, NY, USA
| | - Robert C Hendel
- Department of Medicine, Division of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Nishant R Shah
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Brian G Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Wael Al Jaroudi
- Division of Cardiovascular Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nathan Better
- Department of Nuclear Medicine and Cardiology, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Rami Doukky
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | | | - Amalia Peix
- Nuclear Medicine Department, Institute of Cardiology and Cardiovascular Surgery, La Habana, Cuba
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ibrahim M Saeed
- Virginia Heart, Falls Church, VA, USA
- INOVA Heart and Vascular Institute, Falls Church, VA, USA
- University of Missouri, Kansas City, MO, USA
| | - Rupa M Sanghani
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vikas Veeranna
- Division of Cardiology, Department of Medicine, New England Heart and Vascular Institute, Manchester, NH, USA
| | - Kim A Williams
- Department of Medicine, University of Louisville Department of Medicine, Louisville, KY, USA
| | - David E Winchester
- Malcom Randall VA Medical Center, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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11
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Higaki A, Kawaguchi N, Kurokawa T, Okabe H, Kazatani T, Kido S, Aono T, Matsuda K, Tanaka Y, Hosokawa S, Kosaki T, Kawamura G, Shigematsu T, Kawada Y, Hiasa G, Yamada T, Okayama H. Content-based image retrieval for the diagnosis of myocardial perfusion imaging using a deep convolutional autoencoder. J Nucl Cardiol 2023; 30:540-549. [PMID: 35802346 DOI: 10.1007/s12350-022-03030-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/04/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) plays a crucial role in the optimal treatment strategy for patients with coronary heart disease. We tested the feasibility of feature extraction from MPI using a deep convolutional autoencoder (CAE) model. METHODS Eight hundred and forty-three pairs of stress and rest myocardial perfusion images were collected from consecutive patients who underwent cardiac scintigraphy in our hospital between December 2019 and February 2022. We trained a CAE model to reproduce the input paired image data, so as the encoder to output a 256-dimensional feature vector. The extracted feature vectors were further dimensionally reduced via principal component analysis (PCA) for data visualization. Content-based image retrieval (CBIR) was performed based on the cosine similarity of the feature vectors between the query and reference images. The agreement of the radiologist's finding between the query and retrieved MPI was evaluated using binary accuracy, precision, recall, and F1-score. RESULTS A three-dimensional scatter plot with PCA revealed that feature vectors retained clinical information such as percent summed difference score, presence of ischemia, and the location of scar reported by radiologists. When CBIR was used as a similarity-based diagnostic tool, the binary accuracy was 81.0%. CONCLUSION The results indicated the utility of unsupervised feature learning for CBIR in MPI.
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Affiliation(s)
- Akinori Higaki
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan.
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Toon, Japan.
| | - Naoto Kawaguchi
- Department of Radiology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Tsukasa Kurokawa
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Hikaru Okabe
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Takuro Kazatani
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Shinsuke Kido
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Tetsuya Aono
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Kensho Matsuda
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Yuta Tanaka
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Saki Hosokawa
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Tetsuya Kosaki
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Go Kawamura
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Tatsuya Shigematsu
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Yoshitaka Kawada
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Go Hiasa
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Tadakatsu Yamada
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, 83, Kasuga-machi, Matsuyama, 790-0024, Japan
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12
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Liga R, Neglia D, Cavaleri S, Grasso E, Giorgetti A, Gimelli A. Prognostic impact of patients' management based on anatomic/functional phenotype: a study in patients with chronic coronary syndromes. J Nucl Cardiol 2023; 30:736-747. [PMID: 35941321 DOI: 10.1007/s12350-022-03070-w] [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: 05/10/2022] [Accepted: 07/06/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND In stable coronary artery disease (CAD), the prognostic interaction between clinical variables and treatment appropriateness based on anatomic/functional phenotype needs to be evaluated. METHODS 1585 consecutive patients underwent myocardial perfusion scintigraphy and coronary angiography within 90 days. Obstructive CAD (> 70% stenosis) with downstream moderate-to-severe ischemia (> 10%) was considered significant. Coronary revascularization was considered appropriate if all hemodynamically significant lesions were revascularized, while medical therapy only was deemed appropriate in the absence of hemodynamically significant CAD. RESULTS Obstructive CAD and moderate-to-severe ischemia were documented in 1184 (75%) and 466 (29%) patients, respectively. Over mean follow-up of 4.7 ± 2.5 years, the primary endpoint (cardiac death and non-fatal myocardial infarction) occurred in 132 (8.2%) patients. Of patients with obstructive CAD, 797 (67%) were managed appropriately. Patients' management was inappropriate in 389 patients, because either non-hemodynamically significant lesions were revascularized (50%, including 2 patients with non-obstructive lesions being inappropriately revascularized) or ischemia-causing CAD was left untreated (50%). At multivariate analysis, an inappropriate management (P < .001) was correlated with the primary endpoint, together with previous myocardial infarction (P = .009), lower ejection fraction (P < .001) and higher glucose levels (P < .001). CONCLUSIONS In stable CAD patients, management based on anatomic/functional phenotyping was correlated with a prognostic advantage at long-term follow-up. Correlation between treatment categories and patients' prognosis. A significantly higher event-rate was observed in patients where hemodynamically significant coronary lesions were left untreated-either because MT was not-adherently chosen or in the case of incomplete revascularization-than in those that were revascularized completely (17.6% vs 5.1%; P < .001). Conversely, the revascularization of non-hemodynamically significant CAD correlated with a higher event-rate than that of similar patients managed medically (13.8% vs 8.3%, P = .04). The event-rate of patients in whom coronary revascularization was performed in the presence of hemodynamically significant CAD ('appropriate revascularization') was similar to those with "No CAD/non-obstructive CAD" (5.1% vs 3.5%; P = NS).
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Affiliation(s)
- Riccardo Liga
- Dipartimento Cardio-Toracico e Vascolare, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Pisa, Italy
| | - Danilo Neglia
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy
- Scuola Superiore Sant'Anna, Pisa, Italy
| | - Samuele Cavaleri
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy
| | - Enrico Grasso
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy
| | - Assuero Giorgetti
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy
| | - Alessia Gimelli
- Cardiovascular and Imaging Departments, CNR Research Area, Fondazione CNR/Regione Toscana Gabriele Monasterio, Via G. Moruzzi 1, 56124, Pisa, Italy.
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13
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Bleszynski PA, Schwartz RG. Optimizing patient centered care in the cardiac intensive care unit: Harness the safety, effectiveness, and incremental value of radionuclide perfusion, function, and molecular imaging. J Nucl Cardiol 2023; 30:570-573. [PMID: 34169474 DOI: 10.1007/s12350-021-02691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Peter A Bleszynski
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.
- Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
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14
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Schenone AL, Hutt E, Cremer P, Jaber WA. Utility of nuclear cardiovascular imaging in the cardiac intensive care unit. J Nucl Cardiol 2023; 30:553-569. [PMID: 34109502 DOI: 10.1007/s12350-021-02665-z] [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: 12/02/2020] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
The contemporary Cardiac Intensive Care Unit (CICU) has evolved into a complex unit that admits a heterogeneous mix of patients with a wide range of acute cardiovascular diseases often complicated by multi-organ failure. Although electrocardiography (ECG) and echocardiography are well-established as first-line diagnostic modalities for assessing patients in the CICU, nuclear cardiology imaging has emerged as a useful adjunctive diagnostic modality. The versatility, safety and accuracy of nuclear imaging (e.g., perfusion, metabolism, inflammation) for the assessment of patient with coronary artery disease, ventricular arrhythmias, infiltrative cardiomyopathies, infective endocarditis and inflammatory aortopathies has been proven useful and now often incorporated into the best practices for the management of critically ill cardiac patients. Thus, clinicians must familiarize themselves with the value and current and future applications of nuclear imaging in the management of the cardiac patient in the CICU.
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Affiliation(s)
- Aldo L Schenone
- Cleveland Clinic Heart, Thoracic, Institute Cleveland Clinic, 9500 Euclid Ave. J1-5, Cleveland, OH, 44195, USA
| | - Erika Hutt
- Cleveland Clinic Heart, Thoracic, Institute Cleveland Clinic, 9500 Euclid Ave. J1-5, Cleveland, OH, 44195, USA
| | - Paul Cremer
- Cleveland Clinic Heart, Thoracic, Institute Cleveland Clinic, 9500 Euclid Ave. J1-5, Cleveland, OH, 44195, USA
| | - Wael A Jaber
- Cleveland Clinic Heart, Thoracic, Institute Cleveland Clinic, 9500 Euclid Ave. J1-5, Cleveland, OH, 44195, USA.
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15
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Liga R, Colli A, Taggart DP, Boden WE, De Caterina R. Myocardial Revascularization in Patients With Ischemic Cardiomyopathy: For Whom and How. J Am Heart Assoc 2023; 12:e026943. [PMID: 36892041 PMCID: PMC10111551 DOI: 10.1161/jaha.122.026943] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/14/2022] [Indexed: 03/10/2023]
Abstract
Background Myocardial revascularization has been advocated to improve myocardial function and prognosis in ischemic cardiomyopathy (ICM). We discuss the evidence for revascularization in patients with ICM and the role of ischemia and viability detection in guiding treatment. Methods and Results We searched for randomized controlled trials evaluating the prognostic impact of revascularization in ICM and the value of viability imaging for patient management. Out of 1397 publications, 4 randomized controlled trials were included, enrolling 2480 patients. Three trials (HEART [Heart Failure Revascularisation Trial], STICH [Surgical Treatment for Ischemic Heart Failure], and REVIVED [REVascularization for Ischemic VEntricular Dysfunction]-BCIS2) randomized patients to revascularization or optimal medical therapy. HEART was stopped prematurely without showing any significant difference between treatment strategies. STICH showed a 16% lower mortality with bypass surgery compared with optimal medical therapy at a median follow-up of 9.8 years. However, neither the presence/extent of left ventricle viability nor ischemia interacted with treatment outcomes. REVIVED-BCIS2 showed no difference in the primary end point between percutaneous revascularization or optimal medical therapy. PARR-2 (Positron Emission Tomography and Recovery Following Revascularization) randomized patients to imaging-guided revascularization versus standard care, with neutral results overall. Information regarding the consistency of patient management with viability testing results was available in ≈65% of patients (n=1623). No difference in survival was revealed according to adherence or no adherence to viability imaging. Conclusions In ICM, the largest randomized controlled trial, STICH, suggests that surgical revascularization improves patients' prognosis at long-term follow-up, whereas evidence supports no benefit of percutaneous coronary intervention. Data from randomized controlled trials do not support myocardial ischemia or viability testing for treatment guidance. We propose an algorithm for the workup of patients with ICM considering clinical presentation, imaging results, and surgical risk.
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Affiliation(s)
- Riccardo Liga
- Cardiology Division, Pisa University Hospital and Chair of CardiologyUniversity of PisaItaly
| | - Andrea Colli
- Cardiology Division, Pisa University Hospital and Chair of CardiologyUniversity of PisaItaly
| | - David P. Taggart
- Nuffield Department of Surgical SciencesOxford University John Radcliffe HospitalOxfordUnited Kingdom
| | - William E. Boden
- VA Boston Healthcare SystemBoston University School of MedicineBostonMA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital and Chair of CardiologyUniversity of PisaItaly
- Fondazione VillaSerena per la Ricerca, Città Sant'AngeloItaly
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16
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Ródenas-Alesina E, Romero-Farina G, Herrador L, Jordán P, Espinet-Coll C, Pizzi MN, Ribera A, Ferreira-González I, Aguadé-Bruix S. Development of a risk score for patients with ischaemic cardiomyopathy. Arch Cardiovasc Dis 2023; 116:145-150. [PMID: 36759315 DOI: 10.1016/j.acvd.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Ischaemic cardiomyopathy is a leading cause of heart failure and is associated with a poor prognosis. AIM To evaluate predictors of major adverse cardiovascular events (MACE) and to develop a risk score for the disease. METHODS All patients with ischaemic cardiomyopathy referred to a tertiary hospital between 2010 and 2018 for stress-rest gated single-photon emission computed tomography (SPECT) were included retrospectively (n=747). Clinical and gated SPECT-derived variables were analysed as predictors of MACE, a combined endpoint of cardiovascular mortality, heart failure hospitalization or myocardial infarction during follow-up. A multivariable Cox model using backwards stepwise regression with competing risks was used to select the best parsimonious model. RESULTS After a median follow-up of 4.7 years, 313 patients had MACE (41.9%). Independent predictors of MACE were previous heart failure admission, worsening angina or dyspnoea, estimated glomerular filtration rate ≤60mL/min/1.73 m2, age>73 years, diabetes, atrial fibrillation, end-diastolic volume index>83mL/m2 and>12% of scarred myocardium. A risk score ranging from 0 to 12 classified patients as at intermediate risk (event rate of 4.0 MACE per 100 person-years), high risk (11.3 MACE per 100 person-years) or very high risk (27.8 MACE per 100 person-years). The internally validated area under the curve was 0.720 (95% confidence interval 0.660-0.740) and calibration was adequate (Hosmer-Lemeshow test P=0.28) for MACE. CONCLUSIONS In patients with ischaemic cardiomyopathy, a simple risk score using dichotomic and readily available variables obtained from clinical assessment and gated SPECT accurately predicts the risk of MACE.
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Affiliation(s)
- Eduard Ródenas-Alesina
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035 Barcelona, Spain.
| | - Guillermo Romero-Farina
- Nuclear Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; Centro de Investigación Biomédica En Red: Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Lorena Herrador
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Pablo Jordán
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Carina Espinet-Coll
- Nuclear Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - María Nazarena Pizzi
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035 Barcelona, Spain; Centro de Investigación Biomédica En Red: Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Aida Ribera
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035 Barcelona, Spain; Centro de Investigación Biomédica En Red: Epidemiología y Salud Pública (CIBER-ESP), 28029 Madrid, Spain
| | - Ignacio Ferreira-González
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035 Barcelona, Spain; Centro de Investigación Biomédica En Red: Epidemiología y Salud Pública (CIBER-ESP), 28029 Madrid, Spain
| | - Santiago Aguadé-Bruix
- Nuclear Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; Centro de Investigación Biomédica En Red: Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
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17
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Alam L, Omar AMS, Patel KK. Improved Performance of PET Myocardial Perfusion Imaging Compared to SPECT in the Evaluation of Suspected CAD. Curr Cardiol Rep 2023; 25:281-293. [PMID: 36826689 DOI: 10.1007/s11886-023-01851-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE OF REVIEW Myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) has played a central role in the non-invasive evaluation of patients with obstructive coronary artery disease (CAD) for decades. In this review, we discuss the key differences and advantages of positron emission tomography (PET) MPI over SPECT MPI as it relates to the diagnosis, prognosis, as well as clinical decision-making in patients with suspected CAD. RECENT FINDINGS Stress-induced perfusion abnormalities on SPECT help estimate presence, extent, and location of ischemia and flow-limiting obstructive CAD, help with risk stratification, and serve as a gatekeeper to identify patients who will benefit from downstream revascularization versus medical management. Some of the major limitations of SPECT include soft-tissue attenuation artifacts, underestimation of ischemia due to reliance on relative perfusion assessment, and longer protocols with higher radiation dose when performed with traditional equipment. PET MPI addresses most of these limitations and offers better quality images, higher diagnostic accuracy along with shorter protocols and lower radiation dose to the patient. A special advantage of PET scanning lies in the ability to quantify absolute myocardial blood flow and assess true extent of epicardial involvement along with identifying non-obstructive phenotypes of CAD such as diffuse atherosclerosis and microvascular dysfunction. In addition, stress acquisition at/near peak stress with PET allows us to measure left ventricular ejection fraction reserve and myocardial blood flow reserve, which help with identifying patients at a higher risk of future cardiac events and optimally select candidates for revascularization. The several technical advantages of PET MPI position as a superior method to diagnose obstructive and non-obstructive phenotypes of ischemic heart disease affecting the entirety of the coronary circulation offer incremental value for risk stratification and guide post-test management strategy for patients with suspected CAD.
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Affiliation(s)
- Loba Alam
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alaa Mabrouk Salem Omar
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Krishna K Patel
- Department of Cardiology, Mount Sinai Morningside, New York, NY, USA.
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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18
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Kurup R, Wijeysundera HC, Bagur R, Ybarra LF. Complete Versus Incomplete Percutaneous Coronary Intervention-Mediated Revascularization in Patients With Chronic Coronary Syndromes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:86-92. [PMID: 36266152 DOI: 10.1016/j.carrev.2022.10.003] [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: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
Multivessel coronary artery disease (CAD) is associated with worse outcomes across the spectrum of clinical presentations. The prognostic implications of completeness of revascularization in CAD patients, especially those with chronic coronary syndromes (CCS), remain highly debated. This is largely due to the use of non-standardized definitions for complete revascularization (CR) and incomplete revascularization (ICR) within previously published studies, lack of randomized clinical data, varying revascularization methods and heterogenous study populations. In particular, the utility and effectiveness of PCI-mediated CR for CCS remains unknown. In this review, we discuss the various definitions used for CR vs. ICR, highlight the rationale for pursuing CR and summarise the current literature regarding the effects of PCI-mediated CR on clinical outcomes in patients with CCS.
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Affiliation(s)
- Rahul Kurup
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Rodrigo Bagur
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luiz F Ybarra
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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19
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Adenosine triphosphate (ATP): a safe and effective vasodilator for stress perfusion cardiac magnetic resonance imaging. Clin Radiol 2023; 78:e71-e76. [PMID: 36351853 DOI: 10.1016/j.crad.2022.08.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/16/2022] [Accepted: 08/17/2022] [Indexed: 11/08/2022]
Abstract
AIM To evaluate the efficiency and safety of adenosine triphosphate (ATP) as a stress agent in a cohort of patients undergoing stress perfusion cardiac magnetic resonance imaging (CMRI). MATERIALS AND METHODS This retrospective study was conducted between December 2019 and October 2021. The study recruited patients who underwent stress perfusion CMRI using ATP as a vasodilator. Adverse events, such as chest pain, flushing, dyspnoea, headache, and splenic switch-off (SSO) phenomenon, were evaluated in the patients who underwent stress perfusion CMRI. RESULTS The study included 107 patients (age range: 53 ± 11 years; male:female, 62%:38%). The haemodynamic response (heart rate increased by ≥ 10 beats/min) was quick and observed within 2 minutes of ATP infusion. Scanning was stopped in three patients because of atrioventricular block. CMRI images of seven out of 104 patients were excluded from the final analysis because of inferior quality. During ATP infusion, 37/107 patients (35%) experienced mild adverse events, such as chest pain, flushing, dyspnoea, headache, and atrioventricular block. Myocardial infarction and bronchospasms were not observed during ATP infusion. SSO, a marker of adequate stress, was observed in 91% (94/103) of the patients who underwent stress perfusion CMRI. CONCLUSIONS As a coronary vasodilator, ATP was safe for stress perfusion CMRI. In addition, the adverse events during ATP infusion were mild, which were relieved within 2 minutes of ATP injection cessation. SSO could serve as an indicator of stress success in ATP stress perfusion CMRI.
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Gimelli A, Lakshmanan S, Della Tommasina V, Liga R. What Is New in Risk Assessment in Nuclear Cardiology? Cardiol Clin 2023; 41:197-205. [PMID: 37003677 DOI: 10.1016/j.ccl.2023.01.008] [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: 02/27/2023]
Abstract
Nuclear cardiology techniques allow in-depth evaluation of cardiac patients. A body of literature has established the use of nuclear cardiology. The results obtained with traditional cameras have been reinforced by those obtained with a series of innovations that have revolutionized the field of nuclear cardiology. This article highlights the role of nuclear cardiology in the risk assessment of patients with cardiac disease and sheds light on advancements of nuclear imaging techniques in the cardiovascular field. Patient risk stratification has a key role in modern precision medicine. Nuclear cardiac imaging techniques may quantitatively investigate major disease mechanisms of different cardiac pathologies.
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21
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Ansheles AA. [The Revival of the "Ischemic" Approach in the Assessment of Ischemic Heart Disease: Analysis of Major World Research]. KARDIOLOGIIA 2023; 63:60-67. [PMID: 36749203 DOI: 10.18087/cardio.2023.1.n1478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/31/2020] [Accepted: 02/26/2021] [Indexed: 02/08/2023]
Abstract
This analytical review focuses on large international studies on diagnostics of ischemic heart disease and addresses the role of radionuclide methods in evaluating myocardial perfusion and transient ischemia. Based on the reviewed data, the authors proposed a comprehensive instrumental approach to selecting a tactics for the management of patients with suspected or documented ischemic heart disease and for evaluating their prognosis.
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Affiliation(s)
- A A Ansheles
- Chazov National Medical Research Center of Cardiology, Moscow
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22
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Boden WE, Stone PH. Lessons Learned from the ISCHEMIA Trial for the Management of Patients with Stable Ischemic Heart Disease. Annu Rev Med 2023; 74:189-198. [PMID: 36318679 DOI: 10.1146/annurev-med-042921-124013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The recent landmark International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial was undertaken to assess whether stable angina patients with moderate to severe baseline ischemia would benefit from an invasive approach with revascularization versus a conservative approach of intensive lifestyle intervention and pharmacologic secondary prevention. This trial addressed the hypothesis that treating ischemia with an invasive approach would reduce major adverse cardiac events more than a noninvasive pharmacologic and lifestyle approach. ISCHEMIA is discussed in detail, along with current implications for contemporary management of this very common cardiac disorder afflicting millions of patients worldwide.
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Affiliation(s)
- William E Boden
- VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA;
| | - Peter H Stone
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
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23
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Ko CL, Lin SS, Huang CW, Chang YH, Ko KY, Cheng MF, Wang SY, Chen CM, Wu YW. Polar map-free 3D deep learning algorithm to predict obstructive coronary artery disease with myocardial perfusion CZT-SPECT. Eur J Nucl Med Mol Imaging 2023; 50:376-386. [PMID: 36102963 DOI: 10.1007/s00259-022-05953-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/23/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Deep learning (DL) models have been shown to outperform total perfusion deficit (TPD) quantification in predicting obstructive coronary artery disease (CAD) from myocardial perfusion imaging (MPI). However, previously published methods have depended on polar maps, required manual correction, and normal database. In this study, we propose a polar map-free 3D DL algorithm to predict obstructive disease. METHODS We included 1861 subjects who underwent MPI using cadmium-zinc-telluride camera and subsequent coronary angiography. The subjects were divided into parameterization and external validation groups. We implemented a fully automatic algorithm to segment myocardium, perform registration, and apply normalization. We further flattened the image based on spherical coordinate system transformation. The proposed model consisted of a component to predict patent arteries and a component to predict disease in each vessel. The model was cross-validated in the parameterization group, and then further tested using the external validation group. The performance was assessed by area under receiver operating characteristic curves (AUCs) and compared with TPD. RESULTS Our algorithm preprocessed all images accurately as confirmed by visual inspection. In patient-based analysis, the AUC of the proposed model was significantly higher than that for stress-TPD (0.84 vs 0.76, p < 0.01). In vessel-based analysis, the proposed model also outperformed regional stress-TPD (AUC = 0.80 vs 0.72, p < 0.01). The addition of quantitative images did not improve the performance. CONCLUSIONS Our proposed polar map-free 3D DL algorithm to predict obstructive CAD from MPI outperformed TPD and did not require manual correction or a normal database.
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Affiliation(s)
- Chi-Lun Ko
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shau-Syuan Lin
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Cheng-Wen Huang
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Yu-Hui Chang
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Kuan-Yin Ko
- Department of Nuclear Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Mei-Fang Cheng
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shan-Ying Wang
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chung-Ming Chen
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Yen-Wen Wu
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City, 220, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Graduate Institute of Medicine, Yuan Ze University, Taoyuan, Taiwan.
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24
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Hamzaraj K, Kammerlander A, Gyöngyösi M, Frey B, Distelmaier K, Graf S. Patient Selection and Clinical Indication for Chronic Total Occlusion Revascularization-A Workflow Focusing on Non-Invasive Cardiac Imaging. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010004. [PMID: 36675954 PMCID: PMC9864679 DOI: 10.3390/life13010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Percutaneous coronary intervention of chronic total occlusion (CTO PCI) is a challenging procedure with high complication rates and, as not yet fully understood long-term clinical benefits. Ischemic symptom relief in patients with high ischemic burden is to date the only established clinical indication to undergo CTO PCI, supported by randomized controlled trials. In this context, current guidelines suggest attempting CTO PCI only in non-invasively assessed viable CTO correspondent myocardial territories, with large ischemic areas. Hence, besides a comprehensive coronary angiography lesion evaluation, the information derived from non-invasive cardiac imaging techniques is crucial to selecting candidates who may benefit from the revascularization of the occluded vessel. Currently, there are no clear recommendations for a non-invasive myocardial evaluation or choice of imaging modality pre-CTO PCI. Therefore, selecting among available options is left to the physician's discretion. As CTO PCI is strongly recommended to be carried out explicitly in experienced centers, full access to non-invasive imaging for risk-benefit assessment as well as a systematic institutional evaluation process has to be encouraged. In this framework, we opted to review the current myocardial imaging tools and their use for indicating a CTO PCI. Furthermore, based on our experience, we propose a cost-effective systematic approach for myocardial assessment to help guide clinical decision-making for patients presenting with chronic total occlusions.
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25
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Kuronuma K, Han D, Miller RJH, Rozanski A, Gransar H, Dey D, Hayes SW, Friedman JD, Thomson L, Slomka PJ, Berman DS. Long-term Survival Benefit From Revascularization Compared With Medical Therapy in Patients With or Without Diabetes Undergoing Myocardial Perfusion Single Photon Emission Computed Tomography. Diabetes Care 2022; 45:3016-3023. [PMID: 36001757 DOI: 10.2337/dc22-0454] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the long-term association of survival benefit from early revascularization with the magnitude of ischemia in patients with diabetes compared with those without diabetes using a large observational cohort of patients undergoing single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). RESEARCH DESIGN AND METHODS Of 41,982 patients who underwent stress and rest SPECT-MPI from 1998 to 2017, 8,328 (19.8%) had diabetes. A propensity score was used to match 8,046 patients with diabetes to 8,046 patients without diabetes. Early revascularization was defined as occurring within 90 days after SPECT-MPI. The percentage of myocardial ischemia was assessed from the magnitude of reversible myocardial perfusion defect on SPECT-MPI. RESULTS Over a median 10.3-year follow-up, the annualized mortality rate was higher for the patients with diabetes compared with those without diabetes (4.7 vs. 3.6%; P < 0.001). There were significant interactions between early revascularization and percent myocardial ischemia in patients with and without diabetes (all interaction P values <0.05). After adjusting for confounding variables, survival benefit from early revascularization was observed in patients with diabetes above a threshold of >8.6% ischemia and in patients without diabetes above a threshold of >12.1%. Patients with diabetes receiving insulin had a higher mortality rate (6.2 vs. 4.1%; P < 0.001), but there was no interaction between revascularization and insulin use (interaction P value = 0.405). CONCLUSIONS Patients with diabetes, especially those on insulin treatment, had higher mortality rate compared with patients without diabetes. Early revascularization was associated with a mortality benefit at a lower ischemic threshold in patients with diabetes compared with those without diabetes.
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Affiliation(s)
- Keiichiro Kuronuma
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Cardiology, Nihon University, Tokyo, Japan
| | - Donghee Han
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, New York, NY
| | - Heidi Gransar
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sean W Hayes
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John D Friedman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise Thomson
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
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26
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Massalha S, Keidar Z. Image fusion: the beauty of the truth from the inside and out. J Nucl Cardiol 2022; 29:3278-3280. [PMID: 35381963 DOI: 10.1007/s12350-022-02955-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/06/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Samia Massalha
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel.
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27
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Singh A, Kwiecinski J, Miller RJH, Otaki Y, Kavanagh PB, Van Kriekinge SD, Parekh T, Gransar H, Pieszko K, Killekar A, Tummala R, Liang JX, Di Carli M, Berman DS, Dey D, Slomka PJ. Deep Learning for Explainable Estimation of Mortality Risk From Myocardial Positron Emission Tomography Images. Circ Cardiovasc Imaging 2022; 15:e014526. [PMID: 36126124 PMCID: PMC10035936 DOI: 10.1161/circimaging.122.014526] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND We aim to develop an explainable deep learning (DL) network for the prediction of all-cause mortality directly from positron emission tomography myocardial perfusion imaging flow and perfusion polar map data and evaluate it using prospective testing. METHODS A total of 4735 consecutive patients referred for stress and rest 82Rb positron emission tomography between 2010 and 2018 were followed up for all-cause mortality for 4.15 (2.24-6.3) years. DL network utilized polar maps of stress and rest perfusion, myocardial blood flow, myocardial flow reserve, and spill-over fraction combined with cardiac volumes, singular indices, and sex. Patients scanned from 2010 to 2016 were used for training and validation. The network was tested in a set of 1135 patients scanned from 2017 to 2018 to simulate prospective clinical implementation. RESULTS In prospective testing, the area under the receiver operating characteristic curve for all-cause mortality prediction by DL (0.82 [95% CI, 0.77-0.86]) was higher than ischemia (0.60 [95% CI, 0.54-0.66]; P <0.001), myocardial flow reserve (0.70 [95% CI, 0.64-0.76], P <0.001) or a comprehensive logistic regression model (0.75 [95% CI, 0.69-0.80], P <0.05). The highest quartile of patients by DL had an annual all-cause mortality rate of 11.87% and had a 16.8 ([95% CI, 6.12%-46.3%]; P <0.001)-fold increase in the risk of death compared with the lowest quartile patients. DL showed a 21.6% overall reclassification improvement as compared with established measures of ischemia. CONCLUSIONS The DL model trained directly on polar maps allows improved patient risk stratification in comparison with established methods for positron emission tomography flow or perfusion assessments.
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Affiliation(s)
- Ananya Singh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jacek Kwiecinski
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Robert JH Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiac Sciences, University of Calgary, Calgary AB, Canada
| | - Yuka Otaki
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Paul B. Kavanagh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Serge D. Van Kriekinge
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tejas Parekh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Konrad Pieszko
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Interventional Cardiology and Cardiac Surgery, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
| | - Aditya Killekar
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ramyashree Tummala
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joanna X. Liang
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marcelo Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Daniel S. Berman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J. Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Neumann FJ. Diabetes, heart failure, and myocardial revascularization: Is there a new message from the ISCHEMIA trial? Herz 2022; 47:442-448. [PMID: 35962199 DOI: 10.1007/s00059-022-05132-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 11/24/2022]
Abstract
There is no evidence that the indications for myocardial revascularization differ between patients with and without diabetes. Accepted indications include stable angina that cannot be adequately managed by medication, acute coronary syndromes, severely reduced left ventricular (LV) function due to coronary artery disease, left main stenosis, and advanced coronary artery disease causing substantial inducible ischemia. The recent ISCHEMIA trial challenged the criterion of ischemia. With respect to its primary endpoint, ISCHEMIA showed no benefit of an invasive strategy with systematic myocardial revascularization in patients with stable angina and moderate-to-severe ischemia compared with a conservative strategy. However, myocardial revascularization resulted in a statistically significant and clinically meaningful reduction in angina and an improvement in quality of life. There was a significant reduction in prognostically relevant spontaneous myocardial infarction (MI) in the long term, which came at the cost of an increased rate of peri-interventional MI that was of minor prognostic relevance. The risk profile and number of patients included in the ISCHEMIA trial, as well as the duration of follow-up, are not sufficient to show that the lower incidence of spontaneous infarcts improved survival. In ISCHEMIA, there was no heterogeneity in treatment effect depending on diabetes.
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Affiliation(s)
- Franz-Josef Neumann
- Klinik für Kardiologie und Angiologie, Universitäts-Herzzentrum, Universitätsklinikum Freiburg, Campus Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
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29
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Liga R, Gimelli A. Management of patients with ischaemic cardiomyopathy: is there still a role for ischaemia-guided revascularization? Eur Heart J Cardiovasc Imaging 2022; 23:1312-1313. [PMID: 35909077 DOI: 10.1093/ehjci/jeac154] [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: 11/13/2022] Open
Affiliation(s)
- Riccardo Liga
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Azienda Ospedaliero-Universitaria Pisana and University of Pisa, Via Savi 10, 56100 Pisa, Italy
| | - Alessia Gimelli
- Department of Imaging, Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124 Pisa, Italy
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30
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Boden WE, Kaski JC. Evolving Roles of Optimal Medical Therapy and PCI in Chronic Coronary Syndrome Patients with Stable Angina: Introduction. Cardiovasc Drugs Ther 2022; 36:1005-1009. [DOI: 10.1007/s10557-021-07185-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 01/09/2023]
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31
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Kato T, Momose M, Uemura Y, Naya M, Matsumoto N, Hida S, Yamauchi T, Nakajima T, Suzuki E, Inoko M, Tamaki N. Association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan. J Cardiol 2022; 80:475-481. [PMID: 35835641 DOI: 10.1016/j.jjcc.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/06/2022] [Accepted: 06/12/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial. We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan. METHODS From the data of 2780 patients with stable angina who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referrednon-invasive imaging tests (Japanese Coronary-Angiography or Myocardial Imaging for Angina Pectoris Study), 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1year. RESULTS Patients with ≥10% myocardial ischemia (n=173) were less likely to be women than patients with <10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (6.9% vs. 1.8%, p<0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to <10% myocardial ischemia for MACEs remained significant [adjusted hazard ratio (95% confidence interval), 2.40 (1.09-5.26), p=0.029]. After adjusting including treatments, the risk of MACEs became insignificant between the ≥10% myocardial ischemia group and the <10% myocardial ischemia group [adjusted hazard ratio (95% confidence interval), 1.04 (0.45-2.45), p=0.92]. CONCLUSION The presence of ≥10% myocardial ischemia at diagnosis was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.
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Affiliation(s)
- Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Mitsuru Momose
- Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Science, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoya Matsumoto
- Department of Cardiovascular Medicine, Nihon University, Tokyo, Japan
| | - Satoshi Hida
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Takao Yamauchi
- Cardiovascular Medicine, JCHO Sagamino Hospital, Sagamihara, Japan
| | | | - Eriko Suzuki
- Department of Nuclear Medicine, Hokkaido University, Sapporo, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Ródenas-Alesina E, Romero-Farina G, Jordán P, Herrador L, Espinet-Coll C, Pizzi MN, Ribera A, Barrabés JA, Aguadé-Bruix S, Ferreira-González I. Impact of revascularization guided by functional testing in ischaemic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2022; 23:1304-1311. [PMID: 35781510 DOI: 10.1093/ehjci/jeac125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 06/10/2022] [Indexed: 12/16/2022] Open
Abstract
AIMS The burden of ischaemia is a risk factor for adverse outcomes in ischaemic cardiomyopathy (ICM) but is not systematically tested when deciding on revascularization. Limited data exists in patients with ICM regarding the interaction between ischaemia and early coronary revascularization (ECR). This study sought to determine if the burden of ischaemia modifies the outcomes of ECR in ICM. METHODS AND RESULTS Consecutive patients with ICM (left ventricular ejection fraction < 40%) with a stress-rest gated single-photon emission computed tomography (N = 747) were followed-up for ECR and major cardiovascular events (MACEs, cardiovascular death, myocardial infarction, or heart failure hospitalization). A 1:1 matched population was selected using a propensity score for ECR. The interaction between ischaemia and ECR was evaluated in the matched cohort. In the initial cohort, 131 patients underwent ECR. Of them, 109 were matched to non-ECR patients. After a median follow up of 4.1 years, 102 (46.8%) patients experienced a MACE. The effect of revascularization on MACE was dependent of the percent of ischaemia (P for the interaction at 10% ischaemia = 0.021), so that a trend towards a decreased risk of MACE was seen in patients with >10% of ischaemia [hazard ratio (HR) = 0.59 (0.30-1.18)], whereas a non-significant increase of MACE was observed in those with <10% ischaemia (HR = 1.67 [0.94-2.96]). CONCLUSIONS In a contemporary cohort of patients with ICM, the beneficial effects of ECR may be mediated by the percent of ischaemia. This study supports stress testing in ICM and an ischaemia-guided approach for ECR.
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Affiliation(s)
- Eduard Ródenas-Alesina
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Guillermo Romero-Farina
- Nuclear Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autònoma de Barcelona, Pg. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.,Centro de investigación biomédica en red: enfermedades cardiovasculares (CIBER-CV), 28029 Madrid, Spain.,Medicine and Cardiology Department, Consorci Sanitari de l'Alt Penedès I Garraf (CSAPG), 08720 Vilafranca del Penedès, Barcelona, Spain
| | - Pablo Jordán
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lorena Herrador
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carina Espinet-Coll
- Nuclear Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autònoma de Barcelona, Pg. Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - María Nazarena Pizzi
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de investigación biomédica en red: enfermedades cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Aida Ribera
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de investigación biomédica en red: epidemiología y salud pública (CIBER-ESP), 28029 Madrid, Spain
| | - José A Barrabés
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de investigación biomédica en red: enfermedades cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Santiago Aguadé-Bruix
- Nuclear Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autònoma de Barcelona, Pg. Vall d'Hebron, 119-129, 08035 Barcelona, Spain.,Centro de investigación biomédica en red: enfermedades cardiovasculares (CIBER-CV), 28029 Madrid, Spain
| | - Ignacio Ferreira-González
- Cardiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de investigación biomédica en red: epidemiología y salud pública (CIBER-ESP), 28029 Madrid, Spain
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Edvardsen T, Asch FM, Davidson B, Delgado V, DeMaria A, Dilsizian V, Gaemperli O, Garcia MJ, Kamp O, Lee DC, Neglia D, Neskovic AN, Pellikka PA, Plein S, Sechtem U, Shea E, Sicari R, Villines TC, Lindner JR, Popescu BA. Non-Invasive Imaging in Coronary Syndromes: Recommendations of The European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with The American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr 2022; 16:362-383. [PMID: 35729014 DOI: 10.1016/j.jcct.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway.
| | - Federico M Asch
- MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Brian Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; VA Portland Health Care System, Portland, Oregon
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Mario J Garcia
- Division of Cardiology, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Otto Kamp
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Daniel C Lee
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Danilo Neglia
- Department of Cardiology, Istituto di Scienze della Vita Scuola Superiore Sant Anna Pisa, Pisa, Italy
| | - Aleksandar N Neskovic
- Faculty of Medicine, Department of Cardiology, Clinical Hospital Center Zemun, University of Belgrade, Belgrade, Serbia
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Rochester, Minnesota
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Udo Sechtem
- Cardiologicum Stuttgart and Department of Cardiology, Robert Bosch Krankenhaus, Stuttgart, Germany
| | - Elaine Shea
- Alta Bates Summit Medical Center, Berkeley and Oakland, Berkeley, California
| | - Rosa Sicari
- CNR, Institute of Clinical Physiology, Pisa, Italy
| | - Todd C Villines
- Division of Cardiovascular Medicine, University of Virginia Health System, University of Virginia Health Center, Charlottesville, Virginia
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy Carol Davila Euroecolab, Emergency Institute for Cardiovascular Diseases Prof. Dr. C. C. Iliescu, Bucharest, Romania
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Takura T, Yokoi H, Tanaka N, Matsumoto N, Yoshida E, Nakata T. Health economics-based verification of functional myocardial ischemia evaluation of stable coronary artery disease in Japan: A long-term longitudinal study using propensity score matching. J Nucl Cardiol 2022; 29:1356-1369. [PMID: 33462786 PMCID: PMC9162976 DOI: 10.1007/s12350-020-02502-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The procedural numbers and medical costs of percutaneous coronary intervention (PCI), mainly elective PCI, have been increasing in Japan. Owing to increased interest in the appropriateness of coronary revascularization, we conducted this medical economics-based evaluation of testing and diagnosis of stable coronary artery disease (CAD). METHODS AND RESULTS We reviewed patients' medical insurance data to identify stable CAD patients who underwent coronary computed tomography angiography, cardiac single-photon emission computed tomography, coronary angiography, or fractional flow reserve. Subjects were divided into anatomical and functional evaluation groups according to the modality of testing, and background factors were matched by propensity score. The endpoints were major adverse cardiovascular events (MACE), life years (LYs), medical costs, and cost-effectiveness analysis (CEA). The observations were performed for 36 months. MACE, medical costs, and CEA of the functional group in the overall category were trending to be better than the anatomical group (MACE, P = .051; medical costs: 3,105 US$ vs 4,430 US$, P = .007; CEA: 2,431 US$/LY vs 2,902 US$/LY, P = .043). CONCLUSIONS The functional evaluation approach improved long-term clinical outcomes and reduced cumulative medical costs. As a result, the modality composition of functional myocardial ischemia evaluation was demonstrated to offer superior cost-effectiveness in stable CAD.
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Affiliation(s)
- Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital, International University of Health and Welfare, Fukuoka, Japan
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
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Azarine A, Scalbert F, Garçon P. Cardiac functional imaging. Presse Med 2022; 51:104119. [PMID: 35321846 DOI: 10.1016/j.lpm.2022.104119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/27/2022] [Accepted: 03/11/2022] [Indexed: 01/01/2023] Open
Abstract
During the last 20 years, cardiac imaging has drastically evolved. Positron emission tomography (PET), fast three-dimensional (3D) imaging with the latest generations of echocardiography & multi-detector computed tomography (CT), stress perfusion assessed by magnetic resonance imaging (MRI), blood flow analysis using four-dimensional (4D) flow MRI, all these techniques offer new trends for optimal noninvasive functional cardiac imaging. Dynamic functional imaging is obtained by acquiring images of the heart at different phases of the cardiac cycle, allowing assessment of cardiac motion, function, and perfusion. Between CT and Cardiac MRI (CMR), CMR has the best temporal resolution, which is suitable for functional imaging while cardiac CT provides higher spatial resolution with isotropic data that have an identical resolution in the three dimensions of the space. The latest generations of CT scanners enable whole heart assessment in one beat, offering also an acceptable temporal resolution with the possibility to display the images in a dynamic mode. Another rapidly growing technique using functional and molecular imaging for the assessment of biological and metabolic pathways is the PET using radio-labeled tracers. Meanwhile, the oldest cardiac imaging tool with doppler ultrasound technology has never stopped evolving. Echocardiography today performs 3D imaging, stress perfusion, and myocardial strain assessment, with high temporal resolution. It still is the first line and more accessible exam for the patient. These different modalities are complementary and may be even combined into PET-CT or PET-MRI. The ability to combine the functional/molecular data with anatomical images may implement a new dimension to our diagnostic tools.
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Affiliation(s)
- Arshid Azarine
- Radiology Department, Groupe Hospitalier Paris Saint-Joseph, 185, Rue Raymond Losserand, 75014, Paris, France.
| | - François Scalbert
- Nuclear Medecine Department, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75877, Paris, France
| | - Philippe Garçon
- Cardiology Department, Groupe Hospitalier Paris Saint-Joseph, 185, Rue Raymond Losserand, 75014, Paris, France
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Al-Mallah MH, Ahmed AI, Nabi F, Chang SM, Kleiman NS, Chamsi-Pasha MA, Shah A, Han Y, Zoghbi WA, Mahmarian JJ. Outcomes of patients with moderate-to-severe Ischemia excluded from the ischemia trial. J Nucl Cardiol 2022; 29:1100-1105. [PMID: 34324083 DOI: 10.1007/s12350-021-02679-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial showed no difference in outcomes between medical therapy vs coronary revascularization in the management of patients with stable coronary artery disease. We aimed to determine the percentage of patients with at least moderate ischemia that would have been eligible for enrollment and evaluate the outcomes of those who would not. METHODS Consecutive patients who underwent cardiac single-photon emission computed tomography (SPECT) between April 2016 and September 2019 were identified and all-cause mortality was determined. RESULTS There were a total of 1508 patients (mean age 67 ± 11.6 years, 69.5% males) with any perfusion defect on SPECT. Patients had a high prevalence of cardiac risk factors (73.4% with hypertension and 54.4% with diabetes mellitus.) Nearly half (709, 47%) had moderate-to-severe ischemia but over two-thirds (479/709, 66.3%) had at least one ISCHEMIA trial exclusion criteria. Patients meeting ISCHEMIA enrollment criteria had a significantly lower all-cause mortality than those who would have been excluded (3.91% vs. 11.3%, respectively, P < .001). CONCLUSION Our results show that ISCHEMIA selected a relatively small subset of lower risk patients among the larger higher risk group of patients with moderate-to-severe ischemia typical to most cardiology centers.
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Affiliation(s)
- Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
| | - Ahmed Ibrahim Ahmed
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Faisal Nabi
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Su Min Chang
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Neal S Kleiman
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Mohammed A Chamsi-Pasha
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Alpesh Shah
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Yuishi Han
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - William A Zoghbi
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - John J Mahmarian
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
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McMahon SR, Duvall WL. Is your ischemic patient an ISCHEMIA patient? J Nucl Cardiol 2022; 29:1106-1108. [PMID: 34272675 DOI: 10.1007/s12350-021-02726-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Sean R McMahon
- Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA.
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Ties D, van Dorp P, Pundziute G, Lipsic E, van der Aalst CM, Oudkerk M, de Koning HJ, Vliegenthart R, van der Harst P. Multi-Modality Imaging for Prevention of Coronary Artery Disease and Myocardial Infarction in the General Population: Ready for Prime Time? J Clin Med 2022; 11:jcm11112965. [PMID: 35683356 PMCID: PMC9181560 DOI: 10.3390/jcm11112965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
Cardiovascular disease (CVD) remains a leading cause of death and disability worldwide. Acute myocardial infarction (AMI) causes irreversible myocardial damage, heart failure, life-threatening arrythmias and sudden cardiac death (SCD), and is a main driver of CVD mortality and morbidity. To control the forecasted increase in CVD burden for both the individual and society, improved strategies for the prevention of AMI and SCD are required. Current prevention of AMI and SCD is directed towards risk-modifying interventions, guided by risk assessment using clinical risk prediction scores (CRPSs) and the coronary artery calcium score (CACS). Early detection of more advanced coronary artery disease (CAD), beyond risk assessment by CRPSs or CACS, is a promising strategy to allow personalized treatment for the improved prevention of AMI and SCD in the general population. We review evidence for further testing, beyond CRPSs and CACS, and therapies focusing on promising targets, including subclinical obstructive CAD, high-risk plaques, and silent myocardial ischemia. We also evaluate the potential of multi-modality imaging to enhance the conduction of adequately powered trials to provide high-quality evidence on the impact of add-on tests and therapies in the prevention of AMI and SCD in asymptomatic individuals. To conclude, we discuss the occurrence of AMI and SCD in individuals currently estimated to be at “low-risk” by the current strategy based on CRPSs, and methods to improve prevention of AMI and SCD in this “low-risk” population.
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Affiliation(s)
- Daan Ties
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Paulien van Dorp
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Gabija Pundziute
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Erik Lipsic
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Carlijn M. van der Aalst
- Erasmus Medical Center, Department of Public Health, Erasmus University, 3015 CE Rotterdam, The Netherlands; (C.M.v.d.A.); (H.J.d.K.)
| | - Matthijs Oudkerk
- Institute for Diagnostic Accuracy, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Harry J. de Koning
- Erasmus Medical Center, Department of Public Health, Erasmus University, 3015 CE Rotterdam, The Netherlands; (C.M.v.d.A.); (H.J.d.K.)
| | - Rozemarijn Vliegenthart
- University Medical Center Groningen, Department of Radiology, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Pim van der Harst
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
- University Medical Center Utrecht, Department of Cardiology, University of Utrecht, 3584 CX Utrecht, The Netherlands
- Correspondence:
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Gaede L, Blumenstein J, Möllmann H. [Myocardial revascularization : Controversy over noninvasive and invasive detection of ischemia]. Herz 2022; 47:280-290. [PMID: 35504963 DOI: 10.1007/s00059-022-05110-0] [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] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
With some exceptions, myocardial revascularization in patients with chronic coronary syndrome (CCS) is generally decided on the basis of the extent of myocardial ischemia. Current data indicate that a patient will benefit from revascularization if ischemia is present in more than 10% of the myocardium. Accordingly, all patients presenting with CCS should undergo a noninvasive ischemia test that can answer this question before diagnostic coronary angiography. In order to be able to make a recommendation for revascularization based on scientific data even in those patients who previously had no clear evidence of ischemia, e.g., because of discrepant findings, measurement of the hemodynamic significance of coronary stenoses with a lumen diameter reduction ≥ 50% should be performed during coronary angiography. A decision to revascularize based on hemodynamic significance was shown to be beneficial to patients in several studies.
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Affiliation(s)
- Luise Gaede
- Medizinische Klinik 2, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Johannes Blumenstein
- Klinik für Innere Medizin I, St.-Johannes-Hospital Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland
- Klinikum Oldenburg, Carl-von-Ossietzky-Universität Oldenburg, Oldenburg, Deutschland
| | - Helge Möllmann
- Klinik für Innere Medizin I, St.-Johannes-Hospital Dortmund, Johannesstr. 9-17, 44137, Dortmund, Deutschland.
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40
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Ties D, van Dorp P, Pundziute G, van der Aalst CM, Gratama JWC, Braam RL, Kuijpers D, Lubbers DD, van der Bilt IA, Westenbrink BD, Wolcherink MJO, Doggen CJ, Išgum I, Nijveldt R, de Koning HJ, Vliegenthart R, Oudkerk M, van der Harst P. Early detection of obstructive coronary artery disease in the asymptomatic high-risk population: objectives and study design of the EARLY-SYNERGY trial. Am Heart J 2022; 246:166-177. [PMID: 35038412 DOI: 10.1016/j.ahj.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/11/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) burden for society is expected to steeply increase over the next decade. Improved feasibility and efficiency of preventive strategies is necessary to flatten the curve. Acute myocardial infarction (AMI) is the main determinant of CAD-related mortality and morbidity, and predominantly occurs in individuals with more advanced stages of CAD causing subclinical myocardial ischemia (obstructive CAD; OCAD). Unfortunately, OCAD can remain subclinical until its destructive presentation with AMI or sudden death. Current primary preventive strategies are not designed to differentiate between non-OCAD and OCAD and the opportunity is missed to treat individuals with OCAD more aggressively. METHODS EARLY-SYNERGY is a multicenter, randomized-controlled clinical trial in individuals with coronary artery calcium (CAC) presence to study (1.) the yield of cardiac magnetic resonance stress myocardial perfusion imaging (CMR-MPI) for early OCAD diagnosis and (2) whether early OCAD diagnosis improves outcomes. Individuals with CAC score ≥300 objectified in 2 population-based trials (ROBINSCA; ImaLife) are recruited for study participation. Eligible candidates are randomized 1:1 to cardiac magnetic resonance stress myocardial perfusion imaging (CMR-MPI) or no additional functional imaging. In the CMR-MPI arm, feedback on imaging results is provided to primary care provider and participant in case of guideline-based actionable findings. Participants are followed-up for clinical events, healthcare utilization and quality of life. CONCLUSIONS EARLY-SYNERGY is the first randomized-controlled clinical trial designed to test the hypothesis that subclinical OCAD is widely present in the general at-risk population and that early differentiation of OCAD from non-OCAD followed by guideline-recommended treatment improves outcomes.
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Ramsaran E, Dai Q, Sundaresan D, Leblanc M, Amblihalli V, Muthyala A, Preusse P, Leblanc C, Li P, Andries N, Cai P, Shah N. Mortality in Stable Coronary Disease in Patients With Intermediate- or High-Risk Myocardial Perfusion Imaging. Am J Cardiol 2022; 168:1-10. [PMID: 35074212 DOI: 10.1016/j.amjcard.2021.12.018] [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] [Received: 10/19/2021] [Revised: 12/08/2021] [Accepted: 12/20/2021] [Indexed: 11/01/2022]
Abstract
The management of patients with stable coronary disease and intermediate- or high-risk features on single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) continues to be controversial as to whether they should be treated with an initial invasive strategy (catheterization and revascularization when feasible) or medical therapy alone to improve mortality. We performed a retrospective observational study of 1,946 patients with intermediate- or high-risk SPECT MPI scans performed over a 6-year period (from 2014 to 2019). Each patient was followed from the time of SPECT MPI to 16 months after the last patient was enrolled. The primary end point was all-cause mortality and the secondary end point cardiovascular mortality. Of the eligible 1,697 patients, 1,144 had an intermediate-risk scan, 553 a high-risk scan, 915 had medical therapy alone, and 782 went on an initial invasive strategy. All patients were divided into the following three groups: combined SPECT MPI (both intermediate- and high-risk), high-risk SPECT MPI, and intermediate-risk SPECT MPI groups. After propensity score matching, there was a statistically significant difference in cardiovascular death (5.9% vs 2.7%; p = 0.038) in the medical therapy cohort compared with initial invasive cohort in the combined SPECT MPI group, but no difference in all-cause death (15.7% vs 13%; p = 0.318). On subgroup analysis, in intermediate-risk SPECT MPI group, there was no significant difference in either all-cause death (13.8 vs 11.7%; p = 0.583) or cardiac death (5.4% vs 2.5%; p = 0.16) in conservative cohort compared with invasive strategy cohort. In high-risk SPECT MPI group, conservative therapy cohort had higher cardiac death (11.7% vs 2.5%; p = 0.002) compared with initial invasive strategy cohort, but there was no significant difference in all-cause death (24.5% vs 15.3%; p = 0.052). In conclusion, this study supports that patients with intermediate- or high-risk SPECT MPI scans when considered together or only with high-risk features, derive a cardiovascular mortality benefit with an initial invasive strategy. Patients who had undergone intermediate-risk SPECT MPI had similar outcomes with either medical therapy alone or initial invasive evaluation.
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42
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Incremental prognostic value of spect over CCTA. Int J Cardiol 2022; 358:120-127. [DOI: 10.1016/j.ijcard.2022.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
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43
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Edvardsen T, Asch FM, Davidson B, Delgado V, DeMaria A, Dilsizian V, Gaemperli O, Garcia MJ, Kamp O, Lee DC, Neglia D, Neskovic AN, Pellikka PA, Plein S, Sechtem U, Shea E, Sicari R, Villines TC, Lindner JR, Popescu BA. Non-Invasive Imaging in Coronary Syndromes: Recommendations of The European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with The American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2022; 35:329-354. [PMID: 35379446 DOI: 10.1016/j.echo.2021.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway.
| | - Federico M Asch
- MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Brian Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; VA Portland Health Care System, Portland, Oregon
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Mario J Garcia
- Division of Cardiology, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Otto Kamp
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Daniel C Lee
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Danilo Neglia
- Department of Cardiology, Istituto di Scienze della Vita Scuola Superiore Sant'Anna - Pisa, Pisa, Italy
| | - Aleksandar N Neskovic
- Faculty of Medicine, Department of Cardiology, Clinical Hospital Center Zemun, University of Belgrade, Belgrade, Serbia
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Rochester, Minnesota
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Udo Sechtem
- Cardiologicum Stuttgart and Department of Cardiology, Robert Bosch Krankenhaus, Stuttgart, Germany
| | - Elaine Shea
- Alta Bates Summit Medical Center, Berkeley and Oakland, Berkeley, California
| | - Rosa Sicari
- CNR, Institute of Clinical Physiology, Pisa, Italy
| | - Todd C Villines
- Division of Cardiovascular Medicine, University of Virginia Health System, University of Virginia Health Center, Charlottesville, Virginia
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila"-Euroecolab, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
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Nakano S, Kohsaka S, Chikamori T, Fukushima K, Kobayashi Y, Kozuma K, Manabe S, Matsuo H, Nakamura M, Ohno T, Sawano M, Toda K, Ueda Y, Yokoi H, Gatate Y, Kasai T, Kawase Y, Matsumoto N, Mori H, Nakazato R, Niimi N, Saito Y, Shintani A, Watanabe I, Watanabe Y, Ikari Y, Jinzaki M, Kosuge M, Nakajima K, Kimura T. JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease. Circ J 2022; 86:882-915. [DOI: 10.1253/circj.cj-21-1041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shintaro Nakano
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Kenji Fukushima
- Department of Radiology and Nuclear Medicine, Fukushima Medical University
| | | | - Ken Kozuma
- Cardiology, Teikyo University School of Medicine
| | - Susumu Manabe
- Cardiac Surgery, International University of Health and Welfare Mita Hospital
| | | | - Masato Nakamura
- Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | | | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | - Hiroyoshi Yokoi
- Cardiovascular Center, International University of Health and Welfare Fukuoka Sanno Hospital
| | - Yodo Gatate
- Cardiology, Self-Defense Forces Central Hospital
| | | | | | | | - Hitoshi Mori
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Yuichi Saito
- Cardiovascular Medicine, Chiba University School of Medicine
| | - Ayumi Shintani
- Medical Statistics, Osaka City University Graduate School of Medicine
| | - Ippei Watanabe
- Cardiovascular Medicine, Toho University School of Medicine
| | | | - Yuji Ikari
- Cardiology, Tokai University School of Medicine
| | | | | | - Kenichi Nakajima
- Functional Imaging and Artificial Intelligence, Kanazawa University
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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Kayaert P, Coeman M, Hanet C, Claeys MJ, Desmet W, De Pauw M, Haine S, Taeymans Y. Practice and long-term outcome of unprotected left main PCI: real-world data from a nationwide registry. Acta Cardiol 2022; 77:51-58. [PMID: 33683172 DOI: 10.1080/00015385.2021.1876402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is increasingly performed in significant left main (LM) lesions. Left untreated, the prognosis is poor, but PCI and coronary bypass surgery (CABG) behold risks as well. Additional long-term outcome data might guide future treatment decisions. METHODS Between 2012 and 2019, all 6783 patients who underwent LM PCI were prospectively enrolled in a national registry. Patients with prior CABG or prior LM PCI, and patients presenting in cardiogenic shock or after out-of-hospital cardiac arrest were excluded. From the remaining 5284 patients, baseline and procedural data as well as long-term survival were assessed. RESULTS The annual rate of LM PCI increased from 422 (2.2% of PCIs) in 2012 to 868 in 2018 (3.0%). By 2018, 71% of the interventional cardiologists performed at least 1 LM PCI a year, though only 5 on average. Use of transradial access (TRA) in LM PCI increased from 20.4% in 2012 to 59.5% in 2019. All-cause mortality was 6.0% at 30 days and 18.5% at a mean follow-up of 33.5 months. Independent predictors of higher long-term mortality were older age, diabetes, multivessel disease, an urgent indication, a suboptimal angiographical result, and non-exclusive use of drug-eluting stents. TRAand higher operator and centre LM PCI experience were independent predictors of a lower long-term mortality. CONCLUSION LM PCI is associated with high short- and long-term mortality. Use of TRA and higher expertise in LM PCI were associated with better survival.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Claude Hanet
- Department of Cardiology, Clinique Universitaire de l’université catholique de Louvain, Namur, Belgium
| | - Marc J. Claeys
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
| | - Walter Desmet
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
| | - Michel De Pauw
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
| | - Yves Taeymans
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
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46
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Muscogiuri G, Guglielmo M, Serra A, Gatti M, Volpato V, Schoepf UJ, Saba L, Cau R, Faletti R, McGill LJ, De Cecco CN, Pontone G, Dell’Aversana S, Sironi S. Multimodality Imaging in Ischemic Chronic Cardiomyopathy. J Imaging 2022; 8:jimaging8020035. [PMID: 35200737 PMCID: PMC8877428 DOI: 10.3390/jimaging8020035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/23/2022] [Accepted: 01/27/2022] [Indexed: 02/01/2023] Open
Abstract
Ischemic chronic cardiomyopathy (ICC) is still one of the most common cardiac diseases leading to the development of myocardial ischemia, infarction, or heart failure. The application of several imaging modalities can provide information regarding coronary anatomy, coronary artery disease, myocardial ischemia and tissue characterization. In particular, coronary computed tomography angiography (CCTA) can provide information regarding coronary plaque stenosis, its composition, and the possible evaluation of myocardial ischemia using fractional flow reserve CT or CT perfusion. Cardiac magnetic resonance (CMR) can be used to evaluate cardiac function as well as the presence of ischemia. In addition, CMR can be used to characterize the myocardial tissue of hibernated or infarcted myocardium. Echocardiography is the most widely used technique to achieve information regarding function and myocardial wall motion abnormalities during myocardial ischemia. Nuclear medicine can be used to evaluate perfusion in both qualitative and quantitative assessment. In this review we aim to provide an overview regarding the different noninvasive imaging techniques for the evaluation of ICC, providing information ranging from the anatomical assessment of coronary artery arteries to the assessment of ischemic myocardium and myocardial infarction. In particular this review is going to show the different noninvasive approaches based on the specific clinical history of patients with ICC.
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Affiliation(s)
- Giuseppe Muscogiuri
- Department of Radiology, Istituto Auxologico Italiano IRCCS, San Luca Hospital, University Milano Bicocca, 20149 Milan, Italy
- Correspondence: ; Tel.: +39-329-404-9840
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University, Utrecht University Medical Center, 3584 Utrecht, The Netherlands;
| | - Alessandra Serra
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, 09042 Cagliari, Italy; (A.S.); (L.S.); (R.C.)
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (M.G.); (R.F.)
| | - Valentina Volpato
- Department of Cardiac, Neurological and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, San Luca Hospital, University Milano Bicocca, 20149 Milan, Italy;
| | - Uwe Joseph Schoepf
- Department of Radiology and Radiological Science, MUSC Ashley River Tower, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA; (U.J.S.); (L.J.M.)
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, 09042 Cagliari, Italy; (A.S.); (L.S.); (R.C.)
| | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, 09042 Cagliari, Italy; (A.S.); (L.S.); (R.C.)
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, University of Turin, 10124 Turin, Italy; (M.G.); (R.F.)
| | - Liam J. McGill
- Department of Radiology and Radiological Science, MUSC Ashley River Tower, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC 29425, USA; (U.J.S.); (L.J.M.)
| | - Carlo Nicola De Cecco
- Division of Cardiothoracic Imaging, Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA 30322, USA;
| | | | - Serena Dell’Aversana
- Department of Radiology, Ospedale S. Maria Delle Grazie—ASL Napoli 2 Nord, 80078 Pozzuoli, Italy;
| | - Sandro Sironi
- School of Medicine and Post Graduate School of Diagnostic Radiology, University of Milano-Bicocca, 20126 Milan, Italy;
- Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
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47
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Ryan M, Morgan H, Chiribiri A, Nagel E, Cleland J, Perera D. Myocardial viability testing: all STICHed up, or about to be REVIVED? Eur Heart J 2022; 43:118-126. [PMID: 34791132 PMCID: PMC8757581 DOI: 10.1093/eurheartj/ehab729] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 01/09/2023] Open
Abstract
Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the future.
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Affiliation(s)
- Matthew Ryan
- School of Cardiovascular Medicine and Sciences, King’s College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Holly Morgan
- School of Cardiovascular Medicine and Sciences, King’s College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - John Cleland
- Robertson Centre for Biostatistics, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, King’s College London, Westminster Bridge Road, London SE1 7EH, UK
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48
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Rubidium-82 PET/CT myocardial perfusion imaging. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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49
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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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50
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Armenia EM, Schwartz RG. ISCHEMIA questions and MITNEC answers: Defining and standardizing clinical ischemic jeopardy with SPECT myocardial perfusion imaging. J Nucl Cardiol 2021; 28:2726-2729. [PMID: 32613475 DOI: 10.1007/s12350-020-02237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Erin M Armenia
- University of Rochester Medical Center, Rochester, NY, USA
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