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Gibbons RJ. Myocardial Ischemia in the Management of Chronic Coronary Artery Disease: Past and Present. Circ Cardiovasc Imaging 2021; 14:e011615. [PMID: 33455408 DOI: 10.1161/circimaging.120.011615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
For many years, stress-induced myocardial ischemia has been considered important in the management of chronic coronary artery disease. Early evidence focused on the exercise ECG and the Duke treadmill score. In the 1970s, randomized clinical trials, which compared coronary artery bypass surgery to medical therapy, enrolled patients who were very different from contemporary practice and had inconsistent results. Surgery appeared to be of greatest benefit in high-risk patients defined by anatomy (such as left main disease) or stress-induced ischemia. However, randomized clinical trials of revascularization versus contemporary medical therapy over the past 20 years have been surprisingly negative. Nuclear cardiology substudies from these trials reported inconsistent results. Two observational studies from a single-center provided the best evidence for the use of stress-induced ischemia to identify patients who were most likely to benefit from revascularization. The recently completed ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) was designed to test the hypothesis that revascularization would improve outcomes in patients with moderate-severe ischemia on stress testing. Unfortunately, 14.2% of the randomized patients had either mild or no ischemia on core lab review. Nearly one-quarter of the patients were randomized on the basis of an exercise ECG without imaging. The negative results of the trial reflect the long-term population decline in coronary artery disease and abnormal stress tests, as well as improvements in patient outcome due to optimal medical therapy. Topics requiring further research are presented. The implications of the trial for the use of both stress imaging and coronary computed tomography angiography in clinical practice are examined.
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Di Carli MF, Hachamovitch R. Quantitative Coronary Flow Capacity for Risk Stratification and Clinical Decision Making: Is It Ready for Prime Time? J Nucl Med 2019; 60:407-409. [DOI: 10.2967/jnumed.118.219717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/19/2018] [Indexed: 11/16/2022] Open
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Gibbons RJ, Weintraub WS, Brindis RG. Moving from volume to value for revascularization in stable ischemic heart disease: A review. Am Heart J 2018; 204:178-185. [PMID: 30077336 DOI: 10.1016/j.ahj.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Although percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are both commonly employed in the treatment of stable ischemic heart disease (SIHD), their ability to reduce subsequent heart attacks and death is currently in question. These procedures will come under increasing scrutiny as the healthcare reimbursement system moves away from the traditional fee for service model in favor of "pay for value". OBSERVATION Both international and domestic data show wide variability in the use of PCI and CABG in patients with SIHD. There is evidence of ongoing quality improvement over the last 5 years in reducing the use of inappropriate procedures, but there is still room for improvement. We present ideas regarding health policy interventions that might help manage the transition to value-based payments in this area, including improvements in national registries, more rapid revision of appropriate use criteria, shared decision making, and evidence-based management of PCI in SIHD. CONCLUSIONS AND RELEVANCE The use of revascularization procedures in patients with SIHD is potentially a model for how care might be improved with health care policy intervention. We suggest that the status quo, although apparently improved over the last 5 years, is still unacceptable when 25% of hospitals have a rate of unnecessary PCI in patients with SIHD that approaches 25%.
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Borjesson M, Dellborg M, Niebauer J, LaGerche A, Schmied C, Solberg EE, Halle M, Adami E, Biffi A, Carré F, Caselli S, Papadakis M, Pressler A, Rasmusen H, Serratosa L, Sharma S, van Buuren F, Pelliccia A. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J 2018; 40:13-18. [DOI: 10.1093/eurheartj/ehy408] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 06/26/2018] [Indexed: 01/09/2023] Open
Affiliation(s)
- Mats Borjesson
- Department of Food, Nutrition and Sports Science, Gothenburg University, Skånegatan 14b, Göteborg, Sweden
- Department of Neuroscience and Physiology, Gothenburg University and Sahlgrenska University Hospital/Östra, Diagnosvägen 11, Göteborg, Sweden
| | - Mikael Dellborg
- Department of Medicine, Sahlgrenska University Hospital/Östra, Diagnosvägen 11, Göteborg, Sweden
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Strubergasse 21, Salzburg, Austria
| | - Andre LaGerche
- Baker Heart and Diabetes Institute, 99 Commercial Road, Melbourne VIC, Australia
| | - Christian Schmied
- Kardiologisches Ambulatorium, Sportmedizin/Sportkardiologie, Universitäres Herzzentrum Zürich, Rämistrasse 100, Zurich, Switzerland
| | - Erik E Solberg
- Department of Medicine, Diakonhjemmet Hospital, Diakonveien 12, Oslo, Norway
| | - Martin Halle
- Department of Prevention, Rehabilitation and Sports Medicine, Medical Faculty, University Hospital, Technical University Munich, Georg-Brauchle-Ring 56, Munchen, Germany
| | - Emilio Adami
- Istituto di Medicina e Scienza dello Sport CONI, Largo Piero Gabrielli, 1, Roma, Italy
| | - Alessandro Biffi
- Italian Olympic Committe, Institute for Sports Medicine and Science, Largo Piero Gabrielli, 1, Roma, Italy
| | - Francois Carré
- Sport Medicine Department, Rennes University Hospital, LTSI INSERM UMR 1099, 2 Rue Henri le Guilloux, Rennes, France
| | - Stefano Caselli
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, Roma, Italy
- Ospedale San Pietro Fatebenefratelli, Via Cassia, 600, Roma, Italy
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St George's, University of London, Blackshaw Rd, London, UK
| | - Axel Pressler
- Department of Prevention, Rehabilitation and Sports Medicine, Center for General, Sports and Preventive Cardiology, Technical University of Munich, Georg-Brauchle-Ring 56, Munchen, Germany
| | - Hanne Rasmusen
- Department of Cardiology, Bisbebjerg University Hospital, Bispebjerg Bakke 23, Copenhagen, Denmark
| | - Luis Serratosa
- Hospital Universitario Quironsalud Madrid, Ripoll y De Prado Sport Clinic, FIFA Medical Centre of Excellence, Calle Diego de Velazquez 1, Pozuelo de Alarcon, Madrid, Spain
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St George's, University of London, Blackshaw Rd, London, UK
| | - Frank van Buuren
- Catholic Hospital Southwestfalia, St. Martinus-Hospital Olpe, Hospitalweg 6, Olpe, Germany
| | - Antonio Pelliccia
- Institute for Sports Medicine and Science, Largo Piero Gabrielli, 1, Roma, Italy
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Impact of cardiac hybrid imaging-guided patient management on clinical long-term outcome. Int J Cardiol 2018; 261:218-222. [DOI: 10.1016/j.ijcard.2018.01.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/22/2017] [Accepted: 01/26/2018] [Indexed: 12/29/2022]
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Gibbons RJ. Comparison of ESC and ACC/AHA guidelines for the diagnosis and management of patients with stable coronary heart disease: Are the differences clinically relevant? An American perspective. J Nucl Cardiol 2018; 25:516-520. [PMID: 29150751 DOI: 10.1007/s12350-017-1125-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Raymond J Gibbons
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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Comparative Effectiveness Trials of Imaging-Guided Strategies in Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2017; 10:321-334. [PMID: 28279380 DOI: 10.1016/j.jcmg.2016.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 12/21/2022]
Abstract
The evaluation of patients with suspected stable ischemic heart disease is among the most common diagnostic evaluations with nearly 20 million imaging and exercise stress tests performed annually in the United States. Over the past decade, there has been an evolution in imaging research with an ever-increasing focus on larger registries and randomized trials comparing the effectiveness of varying diagnostic algorithms. The current review highlights recent randomized trial evidence with a particular focus comparing the effectiveness of cardiac imaging procedures within the stable ischemic heart disease evaluation for coronary artery disease detection, angina, and other quality of life measures, and major clinical outcomes. Also highlighted are secondary analyses from these trials on the economic findings related to comparative cost differences across diagnostic testing strategies.
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Abstract
PURPOSE OF REVIEW To summarize the scientific basis of CT derived fractional flow reserve (FFRCT) and present an updated review on the evidence from clinical trials and real-world observational data RECENT FINDINGS: In prospective multicenter studies of patients with stable coronary artery disease (CAD), FFRCT showed high diagnostic performance. More recently, FFRCT has advanced to the realm of clinical utility and real-world clinical practice with emerging data showing that FFRCT when compared to standard care is efficient in safely reducing downstream utilization of invasive coronary angiography (ICA), and costs, as well as improving the diagnostic yield of ICA. Moreover, FFRCT may broaden applicability of frontline coronary CTA testing to patients with high pre-test risk of CAD. Introducing FFRCT into clinical practice has the potential to significantly improve the management of patients with stable CAD. The optimal FFRCT testing interpretation strategy, as well as the relative cost-efficiency of FFRCT against standard noninvasive functional testing, need further investigation.
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Gaibazzi N, Porter T, Lorenzoni V, Pontone G, De Santis D, De Rosa A, Guaricci AI. Effect of Coronary Revascularization on the Prognostic Value of Stress Myocardial Contrast Wall Motion and Perfusion Imaging. J Am Heart Assoc 2017; 6:JAHA.117.006202. [PMID: 28566297 PMCID: PMC5669203 DOI: 10.1161/jaha.117.006202] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The assessment of myocardial perfusion (MP) and wall motion (WM) using contrast dipyridamole echocardiography (cSE‐WMP) improves the sensitivity to detect coronary artery disease and the stratification of cardiac events, but its long‐term value for fatal and nonfatal ischemic cardiac events, also with respect to patients undergoing revascularization or not, remains to be determined. Methods and Results One‐thousand three‐hundred and twenty‐nine patients with suspect or known CAD who underwent cSE‐WMP were followed for a median 5.5 years. The independent prognostic value of cSE‐WMP regarding cardiac death or nonfatal myocardial infarction was related to stress WM and MP, rest ejection fraction, clinical risk factors, and medications. Patients revascularized after cSE‐WMP were separately analyzed to determine whether the procedure influenced outcome and whether this depends on cSE‐WMP results. A total of 125 cardiac fatal and nonfatal ischemic events (9.4%) occurred during the follow‐up (61 deaths, 64 myocardial infarctions). The 5‐year event rate with normal MP and WM was 5.9%, 9.9% with isolated MP defects (normal WM), and 15.5% with both MP and WM abnormalities. In patients not undergoing revascularization (n=1111), reversible MP defects added discrimination value over WM response and clinical factors/medication data (P=0.001), while in the cohort undergoing revascularization (n=218), cSE‐WMP results did not influence outcome. Conclusions cSE‐WMP, with both contrast MP and WM assessments, provides independent, incremental prognostic information regarding ischemic cardiac events at 5 years in patients with known or suspected coronary artery disease. Revascularization reduces cardiac events after an abnormal cSE‐WMP, resulting in outcomes not different from those in patients with normal cSE‐WMP.
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Gibbons RJ. What is the evidence? A call for scientific rigor : Fourteenth Annual Mario S. Verani, MD, Memorial Lecture. J Nucl Cardiol 2017; 24:625-648. [PMID: 27921240 DOI: 10.1007/s12350-016-0738-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Raymond J Gibbons
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 1st St. SW, Rochester, MN, 55905-0001, USA.
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Sechtem U, Mahrholdt H, Ong P, Athanasiadis A, Schäufele T. Testing in Patients With Stable Coronary Artery Disease - The Debate Continues. Circ J 2016; 80:802-10. [PMID: 26984588 DOI: 10.1253/circj.cj-16-0220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The major guidelines on stable coronary artery disease recommend revascularizing patients with large areas of myocardium at risk. The algorithms on how to prove that such high risk is present differ considerably. The opinions on the use of coronary CT (calcium scoring and angiography) vary widely. This review aims to summarize the recommendations of the major guidelines, commenting on differences between the guidelines and discussing whether extending the role of coronary CT angiography should be considered in the light of new CT data.
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Physiological Severity of Coronary Artery Stenosis Depends on the Amount of Myocardial Mass Subtended by the Coronary Artery. JACC Cardiovasc Interv 2016; 9:1548-60. [DOI: 10.1016/j.jcin.2016.04.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 03/25/2016] [Accepted: 04/07/2016] [Indexed: 12/27/2022]
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CT myocardial perfusion imaging: current status and future directions. Clin Radiol 2016; 71:739-49. [DOI: 10.1016/j.crad.2016.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 01/15/2023]
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Sechtem U, Greulich S, Ong P. [Recommendations of the ESC guidelines regarding cardiovascular imaging]. Herz 2016; 41:362-70. [PMID: 27388914 DOI: 10.1007/s00059-016-4453-1] [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] [Indexed: 11/26/2022]
Abstract
Cardiac imaging plays a key role in the diagnosis and risk stratification in the ESC guidelines for the management of patients with stable coronary artery disease. Demonstration of myocardial ischaemia guides the decision which further diagnostic and therapeutic strategy should be followed in these patients. One should, however, not forget that there are no randomised studies supporting this type of management. In patients with a low pretest probability coronary CT angiography is the optimal tool to exclude coronary artery stenoses rapidly and effectively. In the near future, however, better data is needed showing how much cardiac imaging is really necessary and how cost-effective it is in patients with stable coronary artery disease.
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Affiliation(s)
- U Sechtem
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland.
| | - S Greulich
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland
| | - P Ong
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland
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Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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Miller TD, Rodriguez-Porcel M. Your Coronary Calcium Scan Is Positive. JACC Cardiovasc Imaging 2016; 9:590-2. [DOI: 10.1016/j.jcmg.2015.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/16/2015] [Indexed: 10/21/2022]
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Vrints CJ, Senior R, Crea F, Sechtem U. Assessing suspected angina: requiem for coronary computed tomography angiography or exercise electrocardiogram? Eur Heart J 2016; 38:1792-1800. [DOI: 10.1093/eurheartj/ehw065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 01/29/2016] [Indexed: 01/19/2023] Open
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Petretta M, Acampa W, Daniele S, Zampella E, Assante R, Nappi C, Salvatore M, Cuocolo A. Long-Term Survival Benefit of Coronary Revascularization in Patients Undergoing Stress Myocardial Perfusion Imaging. Circ J 2015; 80:485-93. [PMID: 26686993 DOI: 10.1253/circj.cj-15-1093] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We assessed the relationship between clinical outcome and coronary revascularization according to stress-gated myocardial perfusion single-photon emission computed tomography (MPS) in an observational series of patients with suspected or known coronary artery disease (CAD), on long-term follow-up. METHODS AND RESULTS The study group consisted of 2,059 patients. During a median follow-up of 61 months, 184 events occurred (126 cardiac deaths and 58 non-fatal MI). The impact of revascularization during follow-up on event-free survival was evaluated using an extended Cox regression model, adjusting for potential clinical and MPS confounders. Revascularization was treated as a binary non-reversible time-dependent covariate. Predefined interactions tested were: (1) revascularization and summed difference score (SDS); (2) revascularization and post-stress left ventricular (LV) ejection fraction (EF); and (3) SDS and post-stress LVEF. Revascularization had a significant effect on event-free survival (adjusted HR, 0.19; P<0.001). Significant interactions were found between revascularization and SDS (P=0.045), and between LVEF and SDS (P=0.015). The protective effect of revascularization increased as SDS increased. For SDS <6 the reduction in HR was detectable only for reduced LVEF. CONCLUSIONS Both the degree of stress-induced ischemia and LVEF predict the effect of revascularization on outcome in patients with suspected or known CAD. The protective effect of revascularization appears to be greater in patients with severe ischemia and preserved LVEF.
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Affiliation(s)
- Mario Petretta
- Department of Translational Medical Sciences, University of Naples Federico II
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