1
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Ihekwaba U, Johnson N, Choi JS, Savarese G, Orsini N, Khoo J, Squire I, Kardos A. Long-term prognostic value of contemporary stress echocardiography in patients with suspected or known coronary artery disease: systematic review and meta-analysis. Heart 2024:heartjnl-2024-324534. [PMID: 39179369 DOI: 10.1136/heartjnl-2024-324534] [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: 06/04/2024] [Accepted: 07/31/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Long-term outcome of contemporary stress echocardiography has not been systematically assessed. OBJECTIVE To evaluate the association between results of stress echocardiography and patients' outcomes with suspected coronary artery disease using randomised controlled trials. METHODS Multiple electronic databases were searched for studies evaluating long-term outcome (>12 months) of stress echocardiography in patients suspected of coronary artery disease since year 2000. A common-effect model was used to derive pooled estimates. The primary outcome was a composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction, depending on the definition applied in individual trials, termed as major adverse cardiovascular event (MACE). Secondary outcome was all-cause mortality. Positive stress echocardiography result was defined as inducible ischaemia in at least one of the 17 left ventricular segments and negative stress echocardiography with no inducible ischaemia. RESULTS Among a total of six trials, 16 581 subjects underwent either pharmacological or treadmill stress echocardiography, a median follow-up of 31 months (range 21-101). The annual event rate was 1.76% for the composite MACE and 1.35% for all-cause mortality. Compared with negative stress echocardiography, positive stress echocardiography was associated with an increased risk of the MACE and all-cause mortality with an annual event rate of 1.99% vs 1.54% (OR 2.04, 95% CI 1.79 to 2.33) and 1.68% vs 1.02% (OR 2.06, 95% CI 1.80 to 2.35), respectively. CONCLUSION Positive stress echocardiography results were associated with poorer long-term MACE and all-cause mortality. Stress echocardiography results may provide a useful long-term guidance in intensifying preventative treatment in patients with suspected coronary artery disease. PROSPERO REGISTRATION NUMBER CRD42023416766.
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Affiliation(s)
- Ugochukwu Ihekwaba
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
- NIHR Cardiovascular Research Centre, Glenfield Hospital, and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Nicholas Johnson
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Ji Soo Choi
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | | | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Jeffrey Khoo
- Department of Cardiology, Leicester, Leicester University Hospital, UK
| | - Iain Squire
- NIHR Cardiovascular Research Centre, Glenfield Hospital, and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Attila Kardos
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
- Faculty of Medicine and Health Sciences, University of Buckingham, Buckingham, UK
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2
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Thießen N, Schnabel R. [Diagnosis of acute coronary syndrome]. Dtsch Med Wochenschr 2024; 149:488-495. [PMID: 38621682 DOI: 10.1055/a-2163-2586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Acute coronary syndrome is one of the most important differential diagnostic considerations in emergency medicine. It describes the constellation of newly occurring clinical symptoms, often accompanied by typical 12-lead ECG changes and the release of cardiac troponins. The spectrum includes unstable angina pectoris, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). It is important to consistently carry out the diagnostic steps that are crucial for further therapeutic procedures to avoid delaying life-saving invasive coronary diagnostics, without losing sight of the diverse, sometimes time-critical differential diagnoses. Anamnesis and clinical examination form the basis of the further procedure. Further developments of biomarker assays with personalized limit values, new imaging modalities with ever higher resolution and faster imaging methods as well as advances in automated ECG analysis with integration of all findings through artificial intelligence will continue to offer many optimization options in the future diagnosis of acute coronary syndrome.
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3
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Abramenko EE, Ryabova TR, Ryabov VV, Boshchenko AA, Karpov RS. [Stress-Echocardiography in Low-risk Acute Coronary Syndrome Without Persistent ST-segment Elevation Diagnostic Algorithm]. KARDIOLOGIIA 2024; 64:63-71. [PMID: 38597764 DOI: 10.18087/cardio.2024.3.n2430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/05/2023] [Indexed: 04/11/2024]
Abstract
This review addresses the capabilities of stress EchoCG as a simple, non-invasive, non-radiation method for diagnosing occult disorders of coronary blood flow in patients with non-ST-elevation acute coronary syndrome on a low-risk electrocardiogram. The capabilities of the enhanced stress EchoCG protocol are based on supplementing the standard detection of transient disturbances of local contractility, generally associated with coronary artery obstruction, with an assessment of the heart rate reserve, coronary reserve and other parameters. This approach is considered promising for a more complete characterization of heart function during exercise and an accurate prognosis of the clinical case, which allows determining the tactics for patient management not limited to selection for myocardial revascularization.
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Affiliation(s)
- E E Abramenko
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk
| | - T R Ryabova
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk
| | - V V Ryabov
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk
| | - A A Boshchenko
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk
| | - R S Karpov
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk
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4
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Kardos A, Soulis D, Becher H. Multiparametric Stress Echocardiography in the Diagnosis of IOCA and INOCA: Role of CFVR Measurement. JACC Case Rep 2023; 19:101941. [PMID: 37593587 PMCID: PMC10429733 DOI: 10.1016/j.jaccas.2023.101941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 08/19/2023]
Abstract
We present assessment of chest pain patients by multiparametric dobutamine stress echocardiography to differentiate inducible ischemia with obstructive coronary artery disease and with no obstructive coronary artery disease. In addition to the classical regional wall motion abnormality, we illustrate how coronary flow velocity reserve by Doppler echocardiography assists diagnosing coronary microvascular dysfunction. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Attila Kardos
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom
- Faculty of Medicine and Health Sciences, University of Buckingham, Buckingham, UK
| | | | - Harald Becher
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada
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5
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Koh N, Nieman K. Role of cardiac imaging in acute chest pain. Br J Radiol 2023; 96:20220307. [PMID: 36533544 PMCID: PMC9975370 DOI: 10.1259/bjr.20220307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Chest pain is the second most common complaint in the emergency department. The need to diagnose the cause of chest pain in a timely manner and appropriately direct care is crucial. This article discusses the role of imaging in acute chest pain, after first differentiating chest pain into cardiac and non-cardiac causes with upfront clinical and biochemical assessment. The role of non-invasive imaging including point-of-care ultrasound, echocardiography, myocardial perfusion imaging, cardiac MRI, coronary computed tomography angiography and novel cardiac CT applications are discussed. Updates in the literature regarding the role of coronary plaque imaging in acute chest pain are reviewed, as are ongoing challenges and future directions. This includes a discussion on the yield of diagnostic testing in low-risk acute chest pain cohorts vs intermediate-high risk cohorts. The incremental value of further testing in the former is low, which is reflected in contemporary guidelines that discourage the use of costly diagnostic tests in these cohorts. In the latter cohort, emerging evidence has shown specifically the role coronary computed tomography angiography could play in reducing the need for invasive coronary angiography in selective patients where the true probability of acute coronary syndrome is thought to be low. Real-world considerations such as accessibility and affordability are also discussed in the paper because while guidelines offer clinicians the flexibility of evidence-based choice, physician decision must necessarily be made in consideration of real-world constraints.
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Affiliation(s)
- Natalie Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Koen Nieman
- Departments of Cardiovascular Medicine and Radiology, Stanford University, School of Medicine, Stanford, CA, USA
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6
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Abstract
PURPOSE OF REVIEW Ultrasound enhancing agents (UEAs), microbubbles which are composed of lipid or albumin shells containing high molecular weight gases with nonlinear acoustic properties in the ultrasound field, are important components of the diagnostic armamentarium in echocardiography. This review highlights the substantial value of UEAs in delineating endocardial border definition and influencing downstream decision-making in cardiovascular ultrasound. RECENT FINDINGS In this article, we review recent updates to the clinical applications of UEAs, special circumstances regarding use, the impact of use on downstream testing and cost-effectiveness, and recommended approaches for optimizing workflow in the echocardiography laboratory with UEAs. SUMMARY In multiple studies, UEAs have been identified as a useful tool in echocardiography, improving study accuracy and reader confidence, while reducing downstream testing and procedures and resulting in significant changes in clinical management. Despite their proven efficacy and cost-effectiveness, recent studies have suggested utilization remains low, in part due to perceived concerns and workflow issues that impair uptake. With an increasingly broader list of indications for echocardiography, UEAs will continue to play an important role in the diagnosis and management of patients with cardiovascular and noncardiovascular diseases.
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Affiliation(s)
- Ariane M. Fraiche
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School
| | - Jordan B. Strom
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
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7
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Dawson LP, Smith K, Cullen L, Nehme Z, Lefkovits J, Taylor AJ, Stub D. Care Models for Acute Chest Pain That Improve Outcomes and Efficiency. J Am Coll Cardiol 2022; 79:2333-2348. [DOI: 10.1016/j.jacc.2022.03.380] [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: 02/11/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
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8
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Fiore G, Di Maio S, Oppizzi M, De Angelis M, Spessot M, Spoladore R, Slavich M, Bianchi G, Setti E, Di Napoli D, Margonato A, Fragasso G. Role of cardiological specialistic evaluation in patients with chest pain presenting in the emergency department. J Cardiovasc Med (Hagerstown) 2022; 23:363-370. [PMID: 35081073 DOI: 10.2459/jcm.0000000000001299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Aim of this study was to evaluate the impact of cardiological and echocardiographic evaluation in addition to a standard clinical and instrumental approach on diagnostic and prognostic accuracy in patients presenting in the emergency department (ED) with chest pain (CP). Acute coronary syndromes, pulmonary embolism and acute aortic syndromes (AAS) (triple-rule-out/TRO) were considered. METHODS From 7040 patients presenting with CP from 1 January 2015 to 31 December 2017, we randomly selected a sample of 1119. We retrospectively evaluated the clinical course and definitive diagnosis according to the ED final report. A 6-month follow-up to assess incident acute cardiovascular events was made by telephone interview in discharged patients; in hospitalized patients, clinical records were analyzed to evaluate the appropriateness of admissions. Diagnostic and prognostic accuracy wasd estimated through sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, according to the presence or absence of cardiological and echocardiographic consultation. RESULTS Complete information of 1099 patients out of 1119 was retrieved. Seven hundred and eighty-eight patients (71.70%) had been discharged, eight inappropriately (0.73%). Three hundred eleven (28.30%) had been hospitalized, 14 (1.27%) inappropriately. Diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% PPV and 99% NPV, with an overall accuracy of 98.00%. In patients evaluated by the cardiologist in addition to the ED physician (n = 387) we observed an improvement of sensitivity and NPV at the expense of specificity. Among improperly discharged patients, 7/8 had normal troponin, 7/8 normal ECG and only 1 was evaluated by a cardiologist. Only one inappropriately hospitalized patient was not evaluated by a cardiologist. CONCLUSIONS Early consultation with a cardiologist and echocardiography improves clinical judgment in doubtful cases of CP, increasing diagnostic performance mainly by reducing inappropriate patient discharge and guaranteeing a low rate of inappropriate hospitalizations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Davide Di Napoli
- Health Directorate, University Hospital San Raffaele, Milano, Italy
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9
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Thein PM, Mirzaee S, Cameron JD, Nasis A. Left ventricular contractile reserve as a determinant of adverse clinical outcomes: a systematic review. Intern Med J 2022; 52:186-197. [PMID: 35015318 DOI: 10.1111/imj.14995] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 07/02/2020] [Accepted: 07/10/2020] [Indexed: 11/30/2022]
Abstract
An abnormal left ventricular contractile reserve is often seen in patients undergoing stress echocardiogram and may indicate the presence of obstructive coronary artery disease. The techniques and indexes used to identify abnormal left ventricular contractile response and its prognostic value in the absence of known causes has not been well studied. To describe the characteristics and clinical outcomes associated with an abnormal left ventricular contractile response, we performed a systematic review that identified 27 eligible studies. A diverse range of indices were utilised to measure left ventricular contractile reserve, most commonly Δleft ventricular ejection fraction in 11 studies. Dobutamine stress echocardiogram was the most commonly performed modality (19 studies) followed by exercise stress echocardiogram (4 studies), dipyridamole stress echocardiogram (2 studies), invasive hemodynamic measurement (1 study) and dobutamine stress magnetic resonance imaging (1 study). All but one study demonstrated a significant association between the absence of left ventricular contractile reserve and increased rate of cardiovascular events, cardiac death and all-cause mortality.
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Affiliation(s)
- Paul M Thein
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Sam Mirzaee
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Arthur Nasis
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
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10
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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11
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2785] [Impact Index Per Article: 928.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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12
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Mahmoud O, Beer D, Mahmaljy H, Youniss M, Campoverde EH, Elias H, Stanton M, Patel M, Hashmi I, Young K, Kuppuraju R, Jacobs S, Alsaid A. Prevalence and Predictors of Obstructive Coronary Artery Disease in Nonlow-risk Acute Chest Pain Patients Who Rule Out for Myocardial Infarction in the High-sensitivity Troponin Era. Crit Pathw Cardiol 2021; 20:10-15. [PMID: 32511135 DOI: 10.1097/hpc.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The best management approach for chest pain patients who rule out for myocardial infarction (MI) in the high-sensitivity troponin (hsTn) era remains elusive. Patients, especially those with nonlow clinical risk scores, are often referred for inpatient ischemic testing to uncover obstructive coronary artery disease (CAD). Whether the prevalence of obstructive CAD in this cohort is high enough to justify routine testing is not known. METHODS We conducted a retrospective cohort analysis of 1517 emergency department chest pain patients who ruled out for MI by virtue of a stable high-sensitivity troponin T (hsTnT) levels (defined as <5 ng/L intermeasurements increase) and were admitted for inpatient testing. RESULTS Abnormal ischemia evaluation (including 5.9% with evidence of fixed wall motion or perfusion defects) was 11.9%. Of those undergoing invasive angiography (n = 292), significant coronary stenoses (≥70% or unstable lesions) and multivessel CAD occurred in 16.8% and 5.5%, respectively. In a multivariate logistic regression model, known CAD, prior MI, chest pain character, mildly elevated hsTnT, and left ventricular ejection fraction <40% were predictive of an abnormal ischemia evaluation result, whereas electrocardiography findings and the modified History, EKG, Age, Risk factors, and troponin (HEART) score were not. Of note, 30-day adverse cardiac events were strikingly low at 0.4% with no deaths despite an overwhelming majority (>90%) of patients scoring intermediate or high on the modified HEART score. CONCLUSIONS A considerable percentage of acute chest pain patients who rule out for MI by hsTn had evidence of obstructive CAD, and the modified HEART score was not predictive of an abnormal ischemia evaluation.
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Affiliation(s)
- Osama Mahmoud
- From the Heart Institute, Geisinger Medical Center, Danville, PA
| | - Dominik Beer
- From the Heart Institute, Geisinger Medical Center, Danville, PA
| | - Hadi Mahmaljy
- From the Heart Institute, Geisinger Medical Center, Danville, PA
| | - Mohamed Youniss
- From the Heart Institute, Geisinger Medical Center, Danville, PA
| | | | - Hadi Elias
- From the Heart Institute, Geisinger Medical Center, Danville, PA
| | - Matthew Stanton
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Maulin Patel
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Insia Hashmi
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Katelyn Young
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Rajesh Kuppuraju
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Steven Jacobs
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA
| | - Amro Alsaid
- From the Heart Institute, Geisinger Medical Center, Danville, PA
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13
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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14
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Vamvakidou A, Danylenko O, Pradhan J, Kelshiker M, Jones T, Whiteside D, Sethi A, Senior R. Relative clinical value of coronary computed tomography and stress echocardiography-guided management of stable chest pain patients: a propensity-matched analysis. Eur Heart J Cardiovasc Imaging 2020:jeaa303. [PMID: 33232454 DOI: 10.1093/ehjci/jeaa303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The European Society of Cardiology recommends coronary computed tomography (CCT) for the assessment of low-risk patients with suspected stable angina. We aimed to assess in a real-life setting the relative clinical value of stress echocardiography (SE)- and CCT-guided management in this population. METHODS AND RESULTS Patients with stable chest pain and no prior history of coronary artery disease (CAD) who underwent CCT or SE as the initial investigative strategy were propensity-matched (990 patients each group-age: 59 ± 13.2 years, males: 47.9%) to account for baseline differences in cardiovascular risk factors. Inconclusive tests were 6% vs. 3% (P < 0.005) in CCT vs. SE. Severe (≥70% stenosis) on CCT and inducible ischaemia on SE detected obstructive CAD by invasive coronary angiography in 63% vs. 57% patients (P = 0.33). Over the follow-up period (median 717, interquartile range 93-1069 days) more patients underwent invasive coronary angiography (21.5% vs. 7.3%, P < 0.005), revascularization (7.3% vs. 3.5%, P < 0.005), further functional testing 33.4% vs. 8.7% (P < 0.005), but more patients were prescribed statins 8.8% vs. 3.8% (P < 0.005) in the CCT vs. the SE arm, respectively. Combined all-cause mortality and acute myocardial infarction was low-CCT-2.3% and SE-3.3%-with no significant difference (P = 0.16). CONCLUSION Initial SE-guided management was similar for the detection of obstructive CAD, demonstrated better resource utilization, but was associated with reduced prescription of statins although with no difference in medium-term outcome compared to CCT in this very low-risk population. However, a randomized study with longer follow-up is needed to confirm the clinical value of our findings.
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Affiliation(s)
- Anastasia Vamvakidou
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
- The Royal Brompton Hospital, Sydney Street, Chelsea, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
| | - Oleksandr Danylenko
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
- The Royal Brompton Hospital, Sydney Street, Chelsea, SW3 6NP, UK
| | - Jiwan Pradhan
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
| | - Mihir Kelshiker
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
| | - Timothy Jones
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
| | - David Whiteside
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
| | - Amarjit Sethi
- National Heart and Lung Institute, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
- The Ealing Hospital, Uxbridge Road, Southall, UB1 3HW, UK
| | - Roxy Senior
- Department of Cardiology, The Northwick Park Hospital, Watford Rd, Harrow, HA1 3UJ, UK
- The Royal Brompton Hospital, Sydney Street, Chelsea, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK
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15
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Head-to-head comparison of prognostic accuracy in patients undergoing noncardiac surgery of dobutamine stress echocardiography versus computed tomography coronary angiography (PANDA trial): A prospective observational study. J Cardiovasc Comput Tomogr 2020; 14:471-477. [DOI: 10.1016/j.jcct.2020.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/20/2020] [Accepted: 02/03/2020] [Indexed: 12/26/2022]
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16
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Impact of an Outpatient Cardiology-managed Urgent Access and Observation Unit on Hospital Admissions. Crit Pathw Cardiol 2020; 18:113-120. [PMID: 31348069 DOI: 10.1097/hpc.0000000000000186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Alternatives to the emergency department (ED) for expedient and high-value team-based cardiology care for patients with chest pain, volume overload, palpitations, and other urgent, but not life-threatening cardiac conditions are lacking. Here, we report on the development of the Cardiac Direct Access Unit (CDAc), an ambulatory cardiology unit with exam rooms, observation bays, and an advanced heart failure clinic. METHODS Patients referred to the CDAc are seen same-day by an attending cardiologist in a space independent from the ED. We performed a retrospective review of 1146 consecutive patients referred to the CDAc in its first year of operation. Among patients who were referred for urgent same-day evaluation, 60.1% were discharged home without observation. RESULTS Among the patients observed or directly discharged from CDAc, 2.4% were readmitted within 30 days for a related symptom. The highest rate of readmission (7.5%) was for heart failure, which compares favorably with guidelines for readmission benchmarks. CONCLUSION Our first year of data suggests that a cardiology-directed observation unit may serve as a high-value alternative to the ED for appropriately selected patients.
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17
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Atabaeva LS, Saidova MA, Shitov VN, Staroverov II. [Comparison of myocardial contrast stress-echocardiography and standard stress-echocardiography in detecting myocardial ischemia in patients with different severity of coronary artery stenoses]. TERAPEVT ARKH 2020; 92:45-50. [PMID: 32598697 DOI: 10.26442/00403660.2020.04.000506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 11/22/2022]
Abstract
AIM To compare diagnostic value between standard stress-echocardiography and myocardial contrast stress echocardiography in detection of myocardial ischemia in patients with different severity of coronary artery stenoses. MATERIALS AND METHODS Myocardial contrast stress-echocardiography and standard stress-echocardiography were performed in 38 patients with coronary artery stenoses over 50% by angiography. Of all lesions 39 were intermediate (5075%) and 33 over 75% stenoses. Fractional flow reserve (FFR) was measured in 12 coronary arteries. During myocardial contrast stress-echocardiography wall motion and myocardial perfusion was assessed. RESULTS Adequate visualisation increased from 81.6% in unenhanced segments to 96.1% in contrast-enhanced segments. The sensitivity, specificity, and diagnostic accuracy of standard stress-echocardiography and myocardial contrast stress-echocardiography in intermediate (5075%) coronary stenoses were 44%, 83%, 56% and 56%, 94% и 64% respectively compare to angiography. Taking into account the 12 arteries with evaluated FFR, these parameters increased to 52%, 93% и 65% in standard stress-echocardiography and to 68%, 100% and 75% in myocardial contrast stress-echocardiography. In coronary stenoses over 75% the sensitivity, specificity, and diagnostic accuracy of standard stress-echocardiography and myocardial contrast stress-echocardiography were 78%, 88%, 80% and 86%, 100%, 92% respectively Conclusion. Use of contrast-enhanced stress-echorardiography significantly increased the diagnostic value of this method by improving endocardial border visualization and possibilities of myocardial perfusion assessment.
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Affiliation(s)
- L S Atabaeva
- Myasnikov Insitute of Clinical Cardiology, National Medical Research Center for Cardiology
| | - M A Saidova
- Myasnikov Insitute of Clinical Cardiology, National Medical Research Center for Cardiology
| | - V N Shitov
- Myasnikov Insitute of Clinical Cardiology, National Medical Research Center for Cardiology
| | - I I Staroverov
- Myasnikov Insitute of Clinical Cardiology, National Medical Research Center for Cardiology
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18
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Shenouda RB, Bytyçi I, Sobhy M, Henein MY. Reduced regional strain rate is the most accurate dysfunction in predicting culprit lesions in patients with acute coronary syndrome. Clin Physiol Funct Imaging 2019; 40:21-29. [PMID: 31549763 DOI: 10.1111/cpf.12597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/17/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Predicting culprit lesions in acute coronary syndrome (ACS) could be a challenge. The aim of this study was to assess the accuracy of regional wall motion abnormalities (RWMA) using various echocardiographic techniques and ECG changes in predicting the culprit coronary lesion in a group of patients with ACS. METHODS In 80 consecutive patients with ACS (age 55·7 ± 9·4 years, 77% male, 15% with CCS Angina III), an echocardiographic examination of left ventricle (LV) RWMA, tissue Doppler imaging (TDI) and speckle tracking myocardial strain and strain rate (SR) were performed before intervention. RESULTS Of the 80 patients, one-vessel stenosis (>70%) was present in 53 (66%), two-vessel disease in 12 (15%) and multivessel disease in 15 patients (19%). About 51% of patients had hypertension, 40% diabetes and 23% dyslipidaemia. There was no relationship between individual segmental RWMA and SR. Mean regional SR, but not peak strain, correlated with culprit lesion branch: left anterior descending - LAD (r = 0·35, P = 0·005), circumflex LCx (r = 0·32, P = 0·03) and right coronary RCA (r = 0·37, P = 0·01). Only ECG changes in the LAD territory (r = 0·26, P = 0·04) correlated with the culprit lesion. SR of LAD territories ≤-0·74 was 71% sensitive and 70% specific (AUC = 0·70, CI = 0·67-0·93, P = 0·01), SR of LCx territories of ≤-0·67 was 75% sensitive and 63% specific (AUC = 0·72, CI = 0·58-0·87, P = 0·02) and SR of RCA territories ≤-0·83 was 73% sensitive and 71% specific (AUC = 0·80, CI = 0·66-0·93, P = 0·001) in predicting significant stenosis. SR was more accurate than all other techniques in predicting the culprit lesion. CONCLUSION In ACS, mean regional speckle tracking SR is more sensitive than peak strain, TDI, ECG changes and wall motion abnormalities in detecting significant coronary artery stenosis.
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Affiliation(s)
- Rafik B Shenouda
- International Cardiac Centre, Alexandria, Egypt.,Institute of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ibadete Bytyçi
- Institute of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Albania
| | - Mohammed Sobhy
- International Cardiac Centre, Alexandria, Egypt.,Cardiology Department, Alexandria University, Alexandria, Egypt
| | - Michael Y Henein
- Institute of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Molecular and Clinic Research Institute, St George University, London, UK.,Brunel University, Uxbridge, UK
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Shivalkar B, De Keersmaeker A, Van Hoeck N, Belkova P, Van de Heyning CM, De Maeyer C, Vrints C. Is 3D Dobutamine stress echocardiography ready for prime time? Diagnostic and prognostic implications. Eur Heart J Cardiovasc Imaging 2019; 21:428-436. [DOI: 10.1093/ehjci/jez161] [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: 02/27/2019] [Accepted: 06/08/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
Compare the diagnostic accuracy and prognostic value of echo contrast enhanced 2D and 3D Dobutamine stress echocardiography (DSE).
Methods and results
We included 718 patients indicated for DSE. All had standard 2D, and contrast enhanced left ventricular opacification (LVO) for 2D and 3D acquisitions at rest and peak stress. Chi-square test was done to assess relationship between DSE result and early revascularization. Kaplan–Meier plots with Logistic regression analysis predicted late major adverse cardiovascular events (MACE) at a maximum follow-up of 84 months. The mean age was 63 ± 13 years (61% males) and follow-up was obtained in 692/718 (96.4%) patients. Only 32% had excellent baseline image quality. The DSE was abnormal in 19.4% patients on 2D, in 17.1% on 2D-LVO and in 19.1% on 3D-LVO. Early revascularization was performed in, respectively, 32.8%, 45.8%, and in 48.5% of stress-positive 2D, 2D-LVO, and 3D-LVO studies. After excluding the 66 patients receiving early revascularization 68/626 (10.9%) had MACE at a maximum follow-up of 84 months. Kaplan–Meier plots showed that stress-positive 2D-LVO and 3D-LVO studies not receiving early revascularization when assessed separately and combined had significantly worse outcomes for MACE compared with stress-negative patients (OR 3.69; 95% CI: 1.54–8.87; P = 0.011, OR 4.54; 95% CI: 1.72–12.93; P = 0.008, and OR 7.07, 95% CI: 1.62–25.16; P = 0.001, respectively).
Conclusion
Combined use of 2D- and 3D-LVO DSE is ready for prime time considering the feasibility, improved diagnostic accuracy and prognostic value.
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Affiliation(s)
- Bharati Shivalkar
- Department of Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, Antwerp, Belgium
- Department of Cardiology, Delta Hospital, Boulevard du Triomphe 201, Auderghem, Belgium
- Pfizer Biopharmaceuticals, Pleinlaan 17, Brussels, Belgium
| | - Alexander De Keersmaeker
- Department of Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, Antwerp, Belgium
| | - Nathan Van Hoeck
- Department of Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, Antwerp, Belgium
| | - Petra Belkova
- Department of Cardiology, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
| | - Caroline M Van de Heyning
- Department of Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
| | - Catherine De Maeyer
- Department of Cardiology, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
| | - Christiaan Vrints
- Department of Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Wilrijkstraat 10, Edegem, Belgium
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20
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Steeds RP, Wheeler R, Bhattacharyya S, Reiken J, Nihoyannopoulos P, Senior R, Monaghan MJ, Sharma V. Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2019; 6:G17-G33. [PMID: 30921767 PMCID: PMC6477657 DOI: 10.1530/erp-18-0068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022] Open
Abstract
Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.
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Affiliation(s)
- Richard P Steeds
- Department of Cardiology, Institute of Cardiovascular Science, University Hospital Birmingham, Birmingham, UK
| | - Richard Wheeler
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | | | - Joseph Reiken
- Department of Cardiology, Kings College Hospital, London, UK
| | - Petros Nihoyannopoulos
- Department of Cardiology, National Heart Lung Institute, Hammersmith Hospital, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Mark J Monaghan
- Department of Cardiology, Kings College Hospital, London, UK
| | - Vishal Sharma
- Department of Cardiology, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
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21
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Innocenti F, Luzzi M, Donnini C, Zanobetti M, Tassinari I, Caldi F, Pini R. Does an imaging stress-test adds information to prognostic scores in patients with chest pain in the emergency department? Intern Emerg Med 2019; 14:119-125. [PMID: 29845517 DOI: 10.1007/s11739-018-1882-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/18/2018] [Indexed: 11/26/2022]
Abstract
We evaluated the ability of a stress-test (Str-T) to improve the risk stratification based on prognostic scores in patients presenting to the ED with chest pain. Between 2008, June and 2013, December, 1082 patients with chest pain were evaluated with an imaging Str-T. With a retrospective analysis, patients were stratified according to: (1) Florence Prediction Rule as low (0-1, LR-FPR), intermediate (2-4, IR-FPR), high risk (5-6, HR-FPR), respectively, 26, 50 and 24% of patients; (2) HEART score as LR-HEART, (0-3) and HR-HEART (≥4), respectively, 36 and 64%; (3) likelihood of CAD according to NICE guidelines, 10-29% LR-NICE, 30-60% IR-NICE and > 60% HR-NICE, respectively, 12, 18 and 70%. Scores' diagnostic performance was calculated with Str-T as reference. One-month follow-up by a phone call was performed, to investigate the occurrence of new cardiovascular events. In LR and HR patients, FPR and NICE score showed sensitivity 66 vs 93%, specificity 59 vs 19% (both p < 0.001), Positive Predictive Value (PPV) 36 vs 31%, Negative Predictive Value (NPV) 83 vs 87%. Among LR-HEART patients, Str-T was positive for inducible ischemia in 53 (14%) patients and 12 (4%) of them underwent a percutaneous coronary revascularization. The Str-T was negative for inducible ischemia in 760 (70%) patients, positive in 272 (25%), inconclusive in 50 (5%); among patients in the LR and IR subgroups, incidence of CAD (1.3 and 1.6%) and the cumulative incidence of significant events at 1-month follow-up (both 1%) was very low Str-T improved prognostic scores' diagnostic performance in LR- and HR-subgroups.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
| | - Margherita Luzzi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Chiara Donnini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Zanobetti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Irene Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Caldi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
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Li YH, Wang YC, Wang YC, Liu JC, Lee CH, Chen CC, Hsieh IC, Kuo FY, Huang WC, Sung SH, Chiu CZ, Hsu JC, Jen SL, Hwang JJ, Lin JL. 2018 Guidelines of the Taiwan Society of Cardiology, Taiwan Society of Emergency Medicine and Taiwan Society of Cardiovascular Interventions for the management of non ST-segment elevation acute coronary syndrome. J Formos Med Assoc 2018; 117:766-790. [PMID: 30017533 DOI: 10.1016/j.jfma.2018.06.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022] Open
Abstract
In Taiwan, the incidence of non-ST segment elevation acute coronary syndrome (NSTE-ACS) continues to increase in recent years. The purpose of this guideline is to help health care professionals in Taiwan to use adequate tests and treatments for management of NSTE-ACS. For rapid diagnosis, in addition to history and physical examination, 0/3 h rapid diagnosis protocol with high sensitivity cardiac troponin assay is recommended in this guideline. Dual antiplatelet and anticoagulation therapies are important parts in the initial treatment. Risk stratification should be performed to identify high risk patients for early coronary angiography. Through evaluation of the coronary anatomy and other clinical factors, the decision for coronary revascularization, either by percutaneous coronary intervention or coronary artery bypass grafting, should be decided by the heart team. The duration of dual antiplatelet therapy should be given for at least 12 months after discharge. Other secondary preventive medications are also recommended for long term use.
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Affiliation(s)
- Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital, Taichung, Taiwan; Department of Biotechnology, Asia University, Taichung, Taiwan; Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ju-Chi Liu
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shuang Ho Hospital and Taipei Medical University, New Taipei City, Taiwan
| | - Cheng-Han Lee
- Department of Internal Medicine and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Feng-You Kuo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Wei-Chun Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Shih-Hsien Sung
- Department of Medicine, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Chiung-Zuan Chiu
- Division of Cardiology, Shin-Kong Wu Ho Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Jung-Cheng Hsu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shu-Long Jen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Shuang Ho Hospital and Taipei Medical University, New Taipei City, Taiwan.
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Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancellotti P. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur Heart J Cardiovasc Imaging 2018; 18:1205-1205af. [PMID: 28950366 DOI: 10.1093/ehjci/jex182] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 12/16/2022] Open
Abstract
Contrast echocardiography is widely used in cardiology. It is applied to improve image quality, reader confidence and reproducibility both for assessing left ventricular (LV) structure and function at rest and for assessing global and regional function in stress echocardiography. The use of contrast in echocardiography has now extended beyond cardiac structure and function assessment to evaluation of perfusion both of the myocardium and of the intracardiac structures. Safety of contrast agents have now been addressed in large patient population and these studies clearly established its excellent safety profile. This document, based on clinical trials, randomized and multicentre studies and published clinical experience, has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols.
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Affiliation(s)
- Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, Imperial College, Sydney Street, London SW3 6NP, UK
| | | | | | | | - Jose Zamorano
- CIBERCV, University Hospital Ramón y Cajal, Madrid, Spain
| | | | | | | | - Patrizio Lancellotti
- University of Liege Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liege, Belgium
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Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study. Crit Pathw Cardiol 2018; 17:98-104. [PMID: 29768319 DOI: 10.1097/hpc.0000000000000141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ultrasound contrast-enhanced stress echocardiography improves endocardial visualization, but diagnostic test rates versus stress myocardial perfusion imaging (MPI) have not been studied. A prospective randomized trial was performed between April 2012 and October 2014 at a single-center, safety net hospital. Hospitalized patients referred for noninvasive stress imaging were randomized 1:1 to stress echocardiography or stress MPI. The primary outcome was diagnostic test rate defined as interpretable images and achievement of >85% of age-predicted maximal heart rate (for dobutamine and exercise). Rates were assessed among those completing testing and then based solely on image interpretability. Charges and length of stay were secondary outcomes. A total of 240 patients were randomized, and 229 completed testing. Diagnostic test rates were similar for stress echocardiography versus MPI {89.4% [95% confidence interval (CI), 82.2-94.4] vs. 94.8% [95% CI, 89.1-98.1], P = 0.13} and did not differ with multivariable adjustment. Modalities requiring a diagnostic heart rate criteria were more frequently ordered with stress echocardiography (100% vs. 26%; P < 0.001). Therefore, an imaging-based analysis without the 12 individuals who failed to achieve target heart rate (n = 217) was evaluated with diagnostic test rates of 100% versus 94.8% (95% CI, 89.1%-98.1%; P = 0.03) for stress echocardiography and MPI, respectively. Median length of stay did not differ. Median (interquartile range) test-related charges were lower with stress echocardiography: $2,424 ($2400-$2508) versus $3619 ($3584-$3728), P < 0.0001. Overall, tests were positive for ischemia in 8% of patients. In conclusion, contrast-enhanced stress echocardiography provides comparable diagnostic test rates to MPI with lower associated charges.
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Porter TR, Mulvagh SL, Abdelmoneim SS, Becher H, Belcik JT, Bierig M, Choy J, Gaibazzi N, Gillam LD, Janardhanan R, Kutty S, Leong-Poi H, Lindner JR, Main ML, Mathias W, Park MM, Senior R, Villanueva F. Clinical Applications of Ultrasonic Enhancing Agents in Echocardiography: 2018 American Society of Echocardiography Guidelines Update. J Am Soc Echocardiogr 2018; 31:241-274. [DOI: 10.1016/j.echo.2017.11.013] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Shah BN, MacNab A, Lynch J, Hampson R, Senior R, Steeds RP. Stress echocardiography in contemporary clinical cardiology: practical considerations and accreditation. Echo Res Pract 2018; 5:E1-E6. [PMID: 29358185 PMCID: PMC5795358 DOI: 10.1530/erp-17-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 01/09/2018] [Indexed: 11/20/2022] Open
Abstract
Stress echocardiography is a widely utilised test in patients with known or suspected coronary artery disease (CAD), valvular heart disease and cardiomyopathies. Its advantages include the ubiquitous availability of echocardiography, lack of ionising radiation, choice of physiological or pharmacological stressors, good diagnostic accuracy and robust supporting evidence base. SE has evolved significantly as a technique over the past three decades and has benefitted considerably from improvements in overall image quality (superior resolution), machine technology (e.g. digital cine-loop acquisition and side-by-side image display) and development of second-generation ultrasound contrast agents that have improved reader confidence and diagnostic accuracy. The purpose of this article is to review the breadth of SE in contemporary clinical cardiology and discuss the recently launched British Society of Echocardiography (BSE) Stress Echocardiography accreditation scheme.
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Affiliation(s)
- Benoy N Shah
- Wessex Cardiac CentreUniversity Hospital Southampton, Southampton, UK
| | - Anita MacNab
- University Hospital of South ManchesterManchester, UK
| | - Jane Lynch
- University Hospital of South ManchesterManchester, UK
| | | | - Roxy Senior
- Northwick Park HospitalHarrow, UK.,National Heart and Lung InstituteImperial College, London, UK
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 25:895-951. [PMID: 27465769 DOI: 10.1016/j.hlc.2016.06.789] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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Zuin G, Parato VM, Groff P, Gulizia MM, Di Lenarda A, Cassin M, Cibinel GA, Del Pinto M, Di Tano G, Nardi F, Rossini R, Ruggieri MP, Ruggiero E, Scotto di Uccio F, Valente S. ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain. Eur Heart J Suppl 2017; 19:D212-D228. [PMID: 28751843 PMCID: PMC5520764 DOI: 10.1093/eurheartj/sux025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.
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Affiliation(s)
- Guerrino Zuin
- Cardiology Unit, Ospedale dell’Angelo, Mestre, Via Paccagnella, 11 30174 VE, Italy
| | - Vito Maurizio Parato
- Cardiology Rehabilitation, Ospedale Madonna del Soccorso, Cardiology Unit, ASUR Marche/AV5—Madonna del Soccorso Hospital, 4-7, via Luciano Manara, 63074, San Benedetto del Tronto (Ascoli Piceno), Italy
| | - Paolo Groff
- Emergency Department, Ospedale Madonna del Soccorso, San Benedetto del Tronto (Ascoli Piceno), Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Matteo Cassin
- Cardiology Department, A.O. Santa Maria degli Angeli, Pordenone, Italy
| | | | | | | | - Federico Nardi
- Cardiology Department, Ospedale Castelli, Verbania, Italy
| | - Roberta Rossini
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Pia Ruggieri
- Emergency-Admission Department, A.O. San Giovanni-Addolorata, Rome, Italy
| | | | | | - Serafina Valente
- Intensive Integrated Cardiology Department, AOU Careggi, Florence, Italy
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Merchan Ortega G, Bonaque Gonzalez JC, Sanchez Espino AD, Aguado Martin MJ, Navarro Garcia F, Ruiz Lopez F, Ramos Perales F, Zamorano Gomez JL. Long-term prognostic value of peak exercise echocardiogram in patients hospitalized with acute chest pain. Echocardiography 2017; 34:869-875. [PMID: 28378340 DOI: 10.1111/echo.13530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Peak exercise echocardiogram (EEcho) has shown reasonable sensitivity and specificity in detecting significant coronary artery disease (CAD). The objective was to evaluate the prognostic value of EEcho in patients hospitalized for acute chest pain (CP) and its additional prognostic information regarding exercise electrocardiogram test (EECG). METHODS Prospective observational study performed between May 2011 and September 2013, including 250 patients consecutively admitted for acute CP with normal cardiac biomarkers and nondiagnostic electrocardiogram. All patients were prospectively followed for 1 year, and major adverse cardiovascular events (MACE) were recorded: cardiac death, nonfatal myocardial infarction (MI), or angina with coronary revascularization. RESULTS EEcho was positive in 16%. Patients with positive EEcho had a higher incidence of hypertension and higher TIMI risk score, showing significant CAD in 66%. We observed contradictory results (EECG-EEcho) in 20%. Patients with positive EEcho and negative EECG had significant CAD in the 66%, and patients undergoing coronary angiography with negative EEcho and positive EECG did not show significant coronary artery disease. Only positive EEcho (P<.001, HR 0.169; 95% CI, 0.088-0.250) and atrial fibrillation (P<.025, HR 0.125; 95% CI, 0.016-0.233) were independently associated with MACE during follow-up. In patients with negative EEcho, the presence of MACE was 2%. CONCLUSIONS EEcho in patients hospitalized for acute chest pain presents good ability to diagnose acute coronary syndrome, while providing additional information when combined with an EECG in up to 20% of cases. Moreover, a negative EEcho in this cohort seems to provide prognostic information beyond the acute event to predict long-term MACE.
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Gurunathan S, Ahmed A, Pabla J, Karogiannis N, Hua A, Young G, Nalin Shah B, Senior R. The clinical efficacy and long-term prognostic value of stress echocardiography in octogenarians. Heart 2016; 103:517-523. [DOI: 10.1136/heartjnl-2016-310026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 09/03/2016] [Accepted: 09/05/2016] [Indexed: 11/04/2022] Open
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Management of Patients With NSTE-ACS. J Am Coll Cardiol 2016; 68:313-321. [DOI: 10.1016/j.jacc.2016.03.599] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/25/2016] [Accepted: 03/01/2016] [Indexed: 11/24/2022]
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Shah BN, Senior R. Stress echocardiography in patients with morbid obesity. Echo Res Pract 2016; 3:R13-8. [PMID: 27249552 PMCID: PMC4989093 DOI: 10.1530/erp-16-0010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/07/2016] [Indexed: 11/08/2022] Open
Abstract
The incidence of significant obesity is rising across the globe. These patients often have a clustering of cardiovascular risk factors and are frequently referred for noninvasive cardiac imaging tests. Stress echocardiography (SE) is widely used for assessment of patients with known or suspected coronary artery disease (CAD), but its clinical utility in morbidly obese patients (in whom image quality may suffer due to body habitus) has been largely unknown. The recently published Stress Ultrasonography in Morbid Obesity (SUMO) study has shown that SE, when performed appropriately with ultrasound contrast agents (whether performed with physiological or pharmacological stress), has excellent feasibility and appropriately risk stratifies morbidly obese patients, including identification of patients who require revascularization. This article reviews the evidence supporting the use of echocardiographic techniques in morbidly obese patients for assessment of known or suspected CAD and briefly discusses other noninvasive modalities, including magnetic resonance and nuclear techniques, comparing and contrasting these techniques against SE.
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Affiliation(s)
- Benoy N Shah
- Department of Cardiology, Wessex Cardiac Centre, University Hospital Southampton, Southampton, UK
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, UK National Heart & Lung Institute, Imperial College London, London, UK
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Zacharias K, Ahmed A, Shah BN, Gurunathan S, Young G, Acosta D, Senior R. Relative clinical and economic impact of exercise echocardiography vs. exercise electrocardiography, as first line investigation in patients without known coronary artery disease and new stable angina: a randomized prospective study. Eur Heart J Cardiovasc Imaging 2016; 18:195-202. [DOI: 10.1093/ehjci/jew049] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/21/2016] [Indexed: 11/14/2022] Open
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MacLachlan H, Thomas R, Langtree J, Hare C, Mitchell ARJ. Is there a role for a local inpatient CT coronary angiography service in selected patients with acute coronary syndrome? A cohort analysis of inpatient tertiary centre referrals for invasive coronary angiography. Open Heart 2016; 3:e000389. [PMID: 27042324 PMCID: PMC4800760 DOI: 10.1136/openhrt-2015-000389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To conduct a retrospective analysis of inpatients referred for invasive coronary angiography (ICA) at a tertiary centre, with suspected or confirmed acute coronary syndrome (ACS). METHODS A retrospective cohort study was conducted at Jersey General Hospital. We evaluated 198 inpatients referred for ICA with suspected or confirmed ACS over a 3-year period. Patients presenting with ST elevation myocardial infarction were excluded. The primary outcome was to identify the number of patients who did not require subsequent coronary intervention following ICA. Patient variables were measured to establish those who met European Society of Cardiology (ESC) criteria for consideration of CT coronary angiography (CTCA) as an alternative to ICA. Cost of care for those referred for ICA was calculated. RESULTS ICA demonstrated evidence of coronary heart disease requiring coronary intervention in 119 (60%) of the referred patients. 28 (35%) of the patients not requiring coronary intervention at ICA met ESC criteria for preassessment with CTCA. The cost of care for this subgroup was £9089 per patient. Inpatient CTCA was calculated at £376 per patient. CONCLUSIONS Low-intermediate risk patients presenting with suspected or confirmed ACS to hospitals without onsite coronary revascularisation should be considered for in-hospital CTCA before consideration of ICA. Using CTCA as a gatekeeper for targeted ICA appears cost-effective, particularly for hospitals without the required onsite facilities.
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Affiliation(s)
| | - Ranji Thomas
- Department of Cardiology , Jersey General Hospital , Jersey , UK
| | - Jessica Langtree
- Department of Cardiology , Jersey General Hospital , Jersey , UK
| | - Chris Hare
- Department of Cardiology , Jersey General Hospital , Jersey , UK
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Abstract
Noninvasive cardiac imaging has an important role in the assessment of patients with acute-onset chest pain. In patients with suspected acute coronary syndrome (ACS), cardiac imaging offers incremental value over routine clinical assessment, the electrocardiogram, and blood biomarkers of myocardial injury, to confirm or refute the diagnosis of coronary artery disease and to assess future cardiovascular risk. This Review covers the current guidelines and clinical use of the common noninvasive imaging techniques, including echocardiography and stress echocardiography, computed tomography coronary angiography, myocardial perfusion scintigraphy, positron emission tomography, and cardiovascular magnetic resonance imaging, in patients with suspected ACS, and provides an update on the developments in noninvasive imaging techniques in the past 5 years.
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Shah BN, Zacharias K, Pabla JS, Karogiannis N, Calicchio F, Balaji G, Alhajiri A, Ramzy IS, Elghamaz A, Gurunathan S, Khattar RS, Senior R. The clinical impact of contemporary stress echocardiography in morbid obesity for the assessment of coronary artery disease. Heart 2016; 102:370-5. [DOI: 10.1136/heartjnl-2015-308796] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/05/2015] [Indexed: 11/04/2022] Open
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Current approaches for the diagnosis, risk stratification and interventional treatment of patients with acute coronary syndromes without st-segment elevation. КЛИНИЧЕСКАЯ ПРАКТИКА 2015. [DOI: 10.17816/clinpract83255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This article reviews current approaches to diagnosis and determination of the individual risk of patients with acute coronary syndrome without ST-segment elevation. Guidelines for determining the choice of treatment strategy and the time slots for its implementation are discussed. We describe the technical features of the implementation of interventional treatment in this group of patients; the choice of methods of myocardial revascularization is discussed.
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Bouzas-Mosquera A, Peteiro J, Broullón FJ, Álvarez-García N, Rodríguez-Garrido JL, Mosquera VX, Martínez D, Yáñez JC, Vázquez-Rodríguez JM. Incremental value of exercise echocardiography over exercise electrocardiography in a chest pain unit. Eur J Intern Med 2015; 26:720-5. [PMID: 26321649 DOI: 10.1016/j.ejim.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/29/2015] [Accepted: 08/05/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Limited data are available on the added value of exercise echocardiography (ExEcho) over exercise electrocardiography (ExECG) in patients with suspected acute coronary syndromes (ACS) referred to a chest pain unit. We aimed to assess the incremental value of ExEcho over ExECG in this setting. METHODS ExECG and ExEcho were performed in parallel in 1052 patients with suspected ACS, nondiagnostic but interpretable electrocardiograms, and negative serial troponin results. The primary outcome was a composite of coronary death, nonfatal myocardial infarction or unstable angina with angiographic documentation of significant coronary artery disease within 6 months. RESULTS The primary outcome occurred in 2/614 patients (0.3%) with both negative ExECG and ExEcho, 3/60 (5%) with positive ExECG and negative ExEcho, 73/135 (54.1%) with negative ExECG and positive ExEcho, 106/136 (77.9%) with both positive ExECG and ExEcho, and 8/107 (7.5%) with inconclusive results. The addition of ExEcho data to a model based on clinical and ExECG data significantly increased the c statistic from 0.898 to 0.968 (change +0.070, 95% confidence interval 0.052-0.092), with a continuous net reclassification improvement of 1.56 and an integrated discrimination improvement of 22% (p<0.001). Decision curve analysis showed that a strategy of referral to coronary angiography based on ExEcho was associated with the highest net benefit and with the largest reduction in unnecessary coronary angiographies. CONCLUSION ExEcho provides significant incremental prognostic information and higher net clinical benefit than a strategy based on ExECG in patients referred to a chest pain unit for suspected ACS and negative troponin levels.
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Affiliation(s)
| | - Jesús Peteiro
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco J Broullón
- Department of Health Information Technology, Hospital Universitario A Coruña, A Coruña, Spain
| | | | | | - Víctor X Mosquera
- Department of Cardiac Surgery, Hospital Universitario A Coruña, A Coruña, Spain
| | - Dolores Martínez
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Juan C Yáñez
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
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Schroeder J, Hamada S, Gründlinger N, Rubeau T, Altiok E, Ulbrich K, Keszei A, Marx N, Becker M. Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy. Clin Res Cardiol 2015; 105:248-56. [PMID: 26349786 DOI: 10.1007/s00392-015-0916-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Clinical assessment often cannot risk stratify patients hospitalized with chest pain and non-diagnostic electrocardiography (ECG) or myocardial enzymes. An inappropriate admission of patients with non-cardiac chest pain is an enormous cost factor. METHODS 2315 patients who presented in the chest pain unit (CPU) with symptoms suggestive of acute coronary syndrome (ACS) were screened. All patients with relevant changes in ECG or myocardial enzymes were excluded. 268 consecutive patients (mean 58 ± 7 years, 88 men) were prospectively included and underwent echocardiography for left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and strain parameter and a coronary angiography (CA) within 2 ± 1 days after admission. RESULTS Anatomically obstructive coronary artery disease (CAD) (≥70 % diameter stenosis) was present in 110 patients (41 %). The incremental value of LVEF, WMSI, and strain parameters to relevant clinical variables was determined in nested Cox models. Baseline clinical data associated with relevant CAD were age [hazard ratio (HR) 1.31, p = 0.03], arterial hypertension (HR 1.39, p = 0.03) and diabetes (HR 1.46, p = 0.001). The addition of endocardial global circumferential strain (GCS) (HR 1.57, p < 0.001) caused the greatest increment in model power (χ (2) = 43.4, p < 0.001). Optimal cut-off value was calculated as -21.7 % for GCS (sensitivity 87 %, specificity 76 %) to differentiate between these patients. CONCLUSIONS In patients with suspected ACS but without ECG changes or myocardial enzyme abnormalities, myocardial deformation imaging can identify patients at risk. This approach may be applied to improve decision guidance at the CPU for fast discharge of patients with non-cardiac chest pain or prompt cardiological allocation of patients with CAD. CLINICAL TRIAL REGISTRATION NCT 02357641.
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Affiliation(s)
- Joerg Schroeder
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Sandra Hamada
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nina Gründlinger
- Department of Internal Medicine, Hospital St. Brigida, Simmerath, Germany
| | - Tanja Rubeau
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ertunc Altiok
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Katrin Ulbrich
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andras Keszei
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Michael Becker
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
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Corcoran D, Grant P, Berry C. Risk stratification in non-ST elevation acute coronary syndromes: Risk scores, biomarkers and clinical judgment. IJC HEART & VASCULATURE 2015; 8:131-137. [PMID: 26753174 PMCID: PMC4691930 DOI: 10.1016/j.ijcha.2015.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 06/27/2015] [Indexed: 12/22/2022]
Abstract
Undifferentiated chest pain is one of the most common reasons for emergency department attendance and admission to hospitals. Non-ST elevation acute coronary syndrome (NSTE-ACS) is an important cause of chest pain, and accurate diagnosis and risk stratification in the emergency department must be a clinical priority. In the future, the incidence of NSTE-ACS will rise further as higher sensitivity troponin assays are implemented in clinical practice. In this article, we review contemporary approaches for the diagnosis and risk stratification of NSTE-ACS during emergency care. We consider the limitations of current practices and potential improvements. Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE) risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom), in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment.
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Affiliation(s)
- David Corcoran
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, UK
| | - Patrick Grant
- Department of Emergency Medicine, Glasgow Royal Infirmary, G4 0SF, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, UK; BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4260] [Impact Index Per Article: 473.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Zacharias K, Ahmadvazir S, Ahmed A, Shah BN, Acosta D, Senior R. Relative diagnostic, prognostic and economic value of stress echocardiography versus exercise electrocardiography as initial investigation for the detection of coronary artery disease in patients with new onset suspected angina. IJC HEART & VASCULATURE 2015; 7:124-130. [PMID: 28785660 PMCID: PMC5497249 DOI: 10.1016/j.ijcha.2015.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 03/29/2015] [Accepted: 03/31/2015] [Indexed: 02/07/2023]
Abstract
Objectives We hypothesised that stress echocardiography (SE), may be superior to exercise ECG (ExECG), for predicting CAD and outcome, and cost-beneficial, when performed as initial investigation in newly suspected angina. Methods All patients seen in 2011, with suspected angina, no history of CAD, pre-test likelihood of CAD of > 10% and who underwent SE or ExECG as first line were identified retrospectively. Cost to diagnosis was calculated by adding the cost of all tests, up to and including coronary angiography (CA), on an intention-to-treat basis. Follow-up data on cardiac death and myocardial infarction (MI) were collected, 26 months after the presentation of the last study patient. Results A total of 456 patients underwent ExECG (224 (49%) negative, 93 (20%) positive, 139 (31%) inconclusive) and 241 underwent SE (200 (83%) negative, 35 (15%) positive, 6 (2%) inconclusive) as first line. In patients subsequently undergoing CA, CAD was present in 46% (37/80) of patients with positive ExECG vs. 72% (23/32) patients with positive SE (p = 0.01). Mean cost to diagnosis was £456 for the ExECG vs. £360 for the SE group (p = 0.002). Over a mean follow-up period of 31 ± 5 months, cardiac events were 2% each in negative SE vs. negative ExECG (p = 0.9). Conclusions SE is superior to ExECG for prediction of CAD and is cost-beneficial when used as initial test in patients with no history of CAD presenting with suspected angina.
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Affiliation(s)
- Konstantinos Zacharias
- Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.,Centre for Health Informatics and Multi-professional Education, University College London, UK
| | - Shahram Ahmadvazir
- Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK
| | - Asrar Ahmed
- Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK
| | - Benoy N Shah
- Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK
| | - Dionisio Acosta
- Centre for Health Informatics and Multi-professional Education, University College London, UK
| | - Roxy Senior
- Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.,Cardiovascular, Biomedical Research Unit, Department of Cardiology, Royal Brompton Hospital, Imperial College London, London, UK
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Ahmadvazir S, Zacharias K, Shah BN, Pabla JS, Senior R. Role of simultaneous carotid ultrasound in patients undergoing stress echocardiography for assessment of chest pain with no previous history of coronary artery disease. Am Heart J 2014; 168:229-36. [PMID: 25066563 DOI: 10.1016/j.ahj.2014.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 04/12/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND We prospectively explored prevalence of carotid disease (CD), its independent association with coronary artery disease (CAD) and outcome as well as potential impact on management, in patients undergoing stress echocardiography (SE) for new onset chest pain without known CAD. METHODS Accordingly, 591 consecutive patients referred for SE underwent carotid ultrasound. Carotid disease was defined as carotid intima-media thickness (C-IMT) >75th percentile for age and sex and/or presence of plaque. RESULTS Myocardial ischemia was demonstrated in only a minority (11%), but there was a high prevalence of CD (70%). Incidence of CD was similar in patients with and without ischemia (76% versus 69%, P = .26). Carotid data led to reclassification of Framingham risk score categories in 65% of patients as well as more than a third of negative SE patients potentially benefitting from primary prevention therapy. Of the 83 patients undergoing coronary arteriography, 59 (71%) demonstrated coronary atherosclerosis (any atheroma) and 33 (40%) CAD. Positive predictive value of SE for CAD was 56%, but presence of carotid plaque improved it to 70%. Although both CD and plaque showed association with CAD and revascularization, after adjustment for conventional risk factors, only carotid plaque maintained significant association (P = .024 and P = .023, respectively). CONCLUSIONS There is significantly higher prevalence of CD compared with myocardial ischemia in patients undergoing SE and carotid ultrasound for suspected CAD. This can lead to significant Framingham risk score reclassification with important primary prevention implications. Carotid plaque is superior to clinical assessment for the prediction of CAD and improves positive predictive value of SE for CAD in these patients.
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Shah BN, Chahal NS, Bhattacharyya S, Li W, Roussin I, Khattar RS, Senior R. The feasibility and clinical utility of myocardial contrast echocardiography in clinical practice: results from the incorporation of myocardial perfusion assessment into clinical testing with stress echocardiography study. J Am Soc Echocardiogr 2014; 27:520-30. [PMID: 24637056 DOI: 10.1016/j.echo.2014.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND This prospective study investigated whether the incorporation of myocardial contrast echocardiography (MCE) into a clinical stress echocardiography service reproduces the benefits of assessing myocardial perfusion proved previously in research studies. METHODS MCE was performed during physiologic and pharmacologic clinical stress echocardiographic studies, and the value of myocardial perfusion to the reporting echocardiologists was categorized as of benefit (subclassified as incremental benefit over wall motion [WM] or greater confidence with WM) or of no added benefit. The presence and extent of inducible ischemia by WM and myocardial perfusion were documented and correlated with angiographic results in patients who underwent cardiac catheterization. RESULTS In total, 220 patients underwent simultaneous MCE during stress echocardiography by eight different operators. Overall, MCE was of benefit in 193 patients (88%), providing incremental benefit over WM in 25% and greater confidence with WM evaluation in 62%. MCE provided no added benefit in 27 patients (12%). MCE detected significantly more cases of ischemia than WM in the left anterior descending coronary artery territory (65% vs 53%, P = .02) and detected a greater ischemic burden than WM on a per patient basis (median, 5 [interquartile range, 3-8] vs 4 [interquartile range, 2-7] segments; P < .001) and across all coronary territories. MCE correctly identified a greater proportion of patients with multivessel disease than WM (76% vs 56%, P = .02) and a greater ischemic burden in patients with multivessel disease (median, 7 [interquartile range, 4-9] vs 5 [interquartile range, 1-8] segments; P < .001). CONCLUSIONS This prospective study is the first to demonstrate that the excellent feasibility and diagnostic utility of MCE, which have been documented in the research arena, are reproducible in the clinical arena.
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Affiliation(s)
- Benoy N Shah
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Navtej S Chahal
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | | | - Wei Li
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | - Isabelle Roussin
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | - Rajdeep S Khattar
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
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Sun Z. Coronary CT angiography: Beyond morphological stenosis analysis. World J Cardiol 2013; 5:444-452. [PMID: 24392188 PMCID: PMC3879698 DOI: 10.4330/wjc.v5.i12.444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/04/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
Rapid technological developments in computed tomography (CT) imaging technique have made coronary CT angiography an attractive imaging tool in the detection of coronary artery disease. Despite visualization of excellent anatomical details of the coronary lumen changes, coronary CT angiography does not provide hemodynamic changes caused by presence of plaques. Computational fluid dynamics (CFD) is a widely used method in the mechanical engineering field to solve complex problems through analysing fluid flow, heat transfer and associated phenomena by using computer simulations. In recent years, CFD is increasingly used in biomedical research due to high performance hardware and software. CFD techniques have been used to study cardiovascular hemodynamics through simulation tools to assist in predicting the behaviour of circulatory blood flow inside the human body. Blood flow plays a key role in the localization and progression of coronary artery disease. CFD simulation based on 3D luminal reconstructions can be used to analyse the local flow fields and flow profiling due to changes of vascular geometry, thus, identifying risk factors for development of coronary artery disease. The purpose of this article is to provide an overview of the coronary CT-derived CFD applications in coronary artery disease.
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Bhattacharyya S, Chehab O, Khattar R, Lloyd G, Senior R. Stress echocardiography in clinical practice: a United Kingdom National Health Service Survey on behalf of the British Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2013; 15:158-63. [DOI: 10.1093/ehjci/jet082] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Echocardiography in the era of multimodality cardiovascular imaging. BIOMED RESEARCH INTERNATIONAL 2013; 2013:310483. [PMID: 23878804 PMCID: PMC3708397 DOI: 10.1155/2013/310483] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 06/11/2013] [Indexed: 12/17/2022]
Abstract
Echocardiography remains the most frequently performed cardiac imaging investigation and is an invaluable tool for detailed and accurate evaluation of cardiac structure and function. Echocardiography, nuclear cardiology, cardiac magnetic resonance imaging, and cardiovascular-computed tomography comprise the subspeciality of cardiovascular imaging, and these techniques are often used together for a multimodality, comprehensive assessment of a number of cardiac diseases. This paper provides the general cardiologist and physician with an overview of state-of-the-art modern echocardiography, summarising established indications as well as highlighting advances in stress echocardiography, three-dimensional echocardiography, deformation imaging, and contrast echocardiography. Strengths and limitations of echocardiography are discussed as well as the growing role of real-time three-dimensional echocardiography in the guidance of structural heart interventions in the cardiac catheter laboratory.
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