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Kakuta K, Dohi K, Yamada T, Yamanaka T, Kawamura M, Nakamori S, Nakajima H, Tanigawa T, Onishi K, Yamada N, Nakamura M, Ito M. Detection of coronary artery disease using coronary flow velocity reserve by transthoracic Doppler echocardiography versus multidetector computed tomography coronary angiography: influence of calcium score. J Am Soc Echocardiogr 2014; 27:775-85. [PMID: 24679739 DOI: 10.1016/j.echo.2014.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND There have been no clinical data specifying the degree of calcium deposition at which coronary flow velocity reserve (CFVR) measurement using transthoracic Doppler echocardiography surpasses 320-row multidetector computed tomographic coronary angiography (CTCA) in detecting obstructive coronary artery disease. METHODS One hundred seventy patients who underwent invasive coronary angiography, transthoracic Doppler echocardiography, and CTCA were prospectively enrolled. Coronary artery stenosis was defined as percentage diameter stenosis ≥ 50% on invasive coronary angiography. CFVR < 2.0 and narrowing ≥ 50% measured with CTCA were the thresholds indicating the presence of coronary artery stenosis. The degree of coronary artery calcification was also assessed using the Agatston calcium score method by computed tomography. RESULTS The majority of patients (89%) were classified as having either high or intermediate pretest probability of coronary artery disease. Significant coronary artery stenoses by invasive coronary angiography were found in 71 patients and 104 vessels. Although the overall diagnostic performance of CTCA was comparable with that of CFVR measurement for detecting coronary artery stenosis, only the diagnostic performance of CTCA was negatively affected by the extent of a patient's coronary artery calcification. Receiver operating characteristic curve analysis indicated that only CFVR measurement is diagnostically accurate when calcium scores are >319 in the patient-based assessment, 189 for the left anterior descending coronary artery, 98 for the left circumflex coronary artery and 282 for the right coronary artery. CONCLUSIONS Transthoracic Doppler echocardiography and 320-row multidetector CTCA successfully diagnosed significant coronary artery stenosis with high feasibility and accuracy. However, only the diagnostic performance of CTCA was negatively affected by the extent of a patient's coronary artery calcification, and therefore the diagnostic performance of CFVR measurement for detecting coronary artery stenosis surpassed that of CTCA when the calcium score exceeded specified cutoff values.
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Affiliation(s)
- Kentaro Kakuta
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Tomomi Yamada
- Department of Translational Medical Science, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Yamanaka
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
| | - Masaki Kawamura
- Department of Cardiology, Yokkaichi Social Insurance Hospital, Yokkaichi, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroshi Nakajima
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Tanigawa
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Katsuya Onishi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Mashio Nakamura
- Department of Clinical Cardiovascular Research, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
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Blankstein R, Ahmed W, Bamberg F, Rogers IS, Schlett CL, Nasir K, Fontes J, Tawakol A, Brady TJ, Nagurney JT, Hoffmann U, Truong QA. Comparison of Exercise Treadmill Testing With Cardiac Computed Tomography Angiography Among Patients Presenting to the Emergency Room With Chest Pain. Circ Cardiovasc Imaging 2012; 5:233-42. [PMID: 22308274 DOI: 10.1161/circimaging.111.969568] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background—
The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA.
Methods and Results—
The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis >50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 years old or women <50 years old or individuals who achieved at least 13 metabolic equivalents on ETT.
Conclusions—
Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.
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Affiliation(s)
- Ron Blankstein
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Waleed Ahmed
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Fabian Bamberg
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Ian S. Rogers
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Christopher Lothar Schlett
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Khurram Nasir
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Joao Fontes
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Ahmed Tawakol
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Thomas J. Brady
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - John T. Nagurney
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Udo Hoffmann
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
| | - Quynh A. Truong
- From the Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.B.); the Section of Cardiovascular Medicine, Yale University, New Haven, CT (K.N.); the National Heart, Lung, and Blood Institute and Boston University Framingham Heart Study, Framingham, MA (J.F.); and the Cardiac MR PET CT Program (W.A., F.B., I.S.R., C.L.S., A.T., T.J.B., U.H., Q.A.T.), the Division of Cardiology (Q.A.T.), the Department of Radiology (A.T.,
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