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Hamilton GW, Koshy AN, Dinh D, Brennan A, Yeoh J, Yudi MB, Horrigan M, Reid CM, Stub D, Chan W, Oqueli E, Freeman M, Hiew C, Ajani A, Farouque O, Clark DJ. The impact of stress testing to guide PCI in patients with chronic coronary disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00623-7. [PMID: 39174434 DOI: 10.1016/j.carrev.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/20/2024] [Accepted: 08/13/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Guidelines and international appropriate use criteria increasingly endorse non-invasive stress testing to evaluate patients with suspected chronic coronary disease (CCD). We sought to review the real-world utilisation of non-invasive stress testing and investigate whether their use prior to PCI associates with outcomes in patients with CCD. METHODS Consecutive patients from a multicentre registry who underwent PCI for CCD between 2006 and 2018 were included. Clinical characteristics and outcomes were stratified according to whether stress testing was performed prior to PCI (stress vs no-stress groups). The primary outcome was 3-year all-cause mortality. RESULTS Among the 8251 patients included, 4970 (60.2 %) underwent pre-PCI stress testing and this proportion increased over time (p-for-trend<0.001). The stress group had a lower prevalence of prior revascularization, myocardial infarction, or heart failure, and a lower incidence of triple vessel disease, in stent re-stenosis, and ACC/AHA class B2/C lesions (all p < 0.001). When comparing post-procedural outcomes, the stress group had lower rates of arrhythmia (1.5 % vs 2.6 %, p = 0.001), new heart failure (0.2 % vs 0.8 %, p = 0.001), renal impairment, and a shorter length of stay (1.6 vs 2.1 days, p < 0.001). Mortality at 3-years was lower in those undergoing PCI following stress testing (5.8 % vs 8.8 %, p < 0.001). After adjusting for key clinical variables, stress guided revascularization was associated with a significantly lower risk of 3-year mortality (adjusted Hazard Ratio 0.77, 95 % CI 0.64-0.92). CONCLUSIONS In patients with CCD, PCI guided by non-invasive stress testing is increasingly utilized and associated with improved survival. Further studies are necessary to investigate whether this results from differences in patient characteristics, optimized patient selection, or refined choice of target vessel.
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Affiliation(s)
- Garry W Hamilton
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; School of Population Health, Curtin University, Perth, Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - William Chan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health, Ballarat, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia.
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2
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Giga V, Boskovic N, Djordjevic-Dikic A, Beleslin B, Nedeljkovic I, Stankovic G, Tesic M, Jovanovic I, Paunovic I, Aleksandric S. Heart Rate Recovery as a Predictor of Long-Term Adverse Events after Negative Exercise Testing in Patients with Chest Pain and Pre-Test Probability of Coronary Artery Disease from 15% to 65. Diagnostics (Basel) 2023; 13:2229. [PMID: 37443623 DOI: 10.3390/diagnostics13132229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The prognosis of patients with chest pain after a negative exercise test is good, but some adverse events occur in this low-risk group. The aim of our study was to identify predictors of long-term adverse events after a negative exercise test in patients with chest pain and a lower intermediate (15-65%) pre-test probability of coronary artery disease (CAD) and to assess the prognostic value of exercise electrocardiography and exercise stress echocardiography in this group of patients. METHODS We identified from our stress test laboratory database 862 patients with chest pain without previously known CAD and with a pre-test probability of CAD ranging from 15 to 65% (mean 41 ± 14%) who underwent exercise testing. Patients were followed for the occurrence of death, non-fatal myocardial infarction (MI) and clinically guided revascularization. RESULTS During the median follow-up of 94 months, 87 patients (10.1%) had an adverse event (AE). A total of 30 patients died (3.5%), 23 patients suffered non-fatal MI (2.7%) and 34 patients (3.9%) had clinically guided revascularization (20 patients percutaneous and 14 patients surgical revascularizations). Male gender, age, the presence of diabetes and a slow heart rate recovery (HRR) in the first minute after exercise were independently related to the occurrence of AEs. Adverse events occurred in 10.3% of patients who were tested by exercise stress echocardiography and in 10.0% of those who underwent stress electrocardiography (p = 0.888). CONCLUSION The risk of AEs after negative exercise testing in patients with a pre-test probability of CAD of 15-65% is low. Male patients with a history of diabetes and slow HRR in the first minute after exercise have an increased risk of an adverse outcome.
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Affiliation(s)
- Vojislav Giga
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Boskovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Nedeljkovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Goran Stankovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Milorad Tesic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivana Jovanovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivana Paunovic
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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3
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Gaba P, Gersh BJ, Muller J, Narula J, Stone GW. Evolving concepts of the vulnerable atherosclerotic plaque and the vulnerable patient: implications for patient care and future research. Nat Rev Cardiol 2023; 20:181-196. [PMID: 36151312 DOI: 10.1038/s41569-022-00769-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenarios, revascularization of these atherosclerotic plaques has not substantially improved freedom from death or myocardial infarction, questioning the utility of contemporary revascularization strategies to improve prognosis. Advances in non-invasive and invasive imaging techniques have helped to identify the characteristics of obstructive and non-obstructive plaques that are precursors for plaque progression and future acute coronary syndromes as well as cardiac death. These 'vulnerable plaques' develop as a consequence of systemic inflammation and are prone to inducing thrombosis. Vulnerable plaques most commonly have a large plaque burden with a well-formed necrotic core and thin fibrous cap and are metabolically active. Perivascular adipose tissue might, in some patients, be used as a surrogate for coronary inflammation and predict future risk of adverse cardiac events. Vulnerable plaques can be identified in their quiescent state, offering the potential for therapeutic passivation. In this Review, we describe the biological and compositional features of vulnerable plaques, the non-invasive and invasive diagnostic modalities to characterize vulnerable plaques, the prognostic utility of identifying vulnerable plaques, and the future studies needed to explore the value of intensified pharmacological and focal treatments of vulnerable plaques.
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Affiliation(s)
- Prakriti Gaba
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - James Muller
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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4
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Kurup R, Wijeysundera HC, Bagur R, Ybarra LF. Complete Versus Incomplete Percutaneous Coronary Intervention-Mediated Revascularization in Patients With Chronic Coronary Syndromes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:86-92. [PMID: 36266152 DOI: 10.1016/j.carrev.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
Multivessel coronary artery disease (CAD) is associated with worse outcomes across the spectrum of clinical presentations. The prognostic implications of completeness of revascularization in CAD patients, especially those with chronic coronary syndromes (CCS), remain highly debated. This is largely due to the use of non-standardized definitions for complete revascularization (CR) and incomplete revascularization (ICR) within previously published studies, lack of randomized clinical data, varying revascularization methods and heterogenous study populations. In particular, the utility and effectiveness of PCI-mediated CR for CCS remains unknown. In this review, we discuss the various definitions used for CR vs. ICR, highlight the rationale for pursuing CR and summarise the current literature regarding the effects of PCI-mediated CR on clinical outcomes in patients with CCS.
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Affiliation(s)
- Rahul Kurup
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Rodrigo Bagur
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luiz F Ybarra
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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5
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Kardos A, Senior R, Becher H. Commentary: Vasodilator Myocardial Perfusion Cardiac Magnetic Resonance Imaging Is Superior to Dobutamine Stress Echocardiography in the Detection of Relevant Coronary Artery Stenosis: A Systematic Review and Meta-Analysis on Their Diagnostic Accuracy. Front Cardiovasc Med 2021; 8:694323. [PMID: 34179149 PMCID: PMC8222596 DOI: 10.3389/fcvm.2021.694323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital, Milton Keynes, United Kingdom.,School of Sciences and Medicine, University of Buckingham, Buckingham, United Kingdom
| | - Roxy Senior
- Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Harald Becher
- ABACUS, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, AB, Canada
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6
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Echocardiography, an Indispensable Tool for the Management of Diabetics, with or without Coronary Artery Disease, in Clinical Practice. ACTA ACUST UNITED AC 2020; 56:medicina56120709. [PMID: 33352952 PMCID: PMC7767240 DOI: 10.3390/medicina56120709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 12/28/2022]
Abstract
Diabetes mellitus is a major factor contributing to the development of cardiovascular disease. As morbidity and mortality rates rise dramatically, when target organ damage develops pre-symptomatic assessment is critical for the management of diabetic patients. Echocardiography is a noninvasive and reproducible method that may aid in risk stratification and in evaluation of treatment effects. The aim of this review is to analyze the echocardiographic techniques which can detect early alteration in cardiac function in patients with diabetes.
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7
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Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. Arch Cardiovasc Dis 2020; 114:150-172. [PMID: 33309203 DOI: 10.1016/j.acvd.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
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8
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Gaba P, Gersh BJ, Ali ZA, Moses JW, Stone GW. Complete versus incomplete coronary revascularization: definitions, assessment and outcomes. Nat Rev Cardiol 2020; 18:155-168. [PMID: 33067581 DOI: 10.1038/s41569-020-00457-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Coronary artery disease is the leading cause of morbidity and mortality worldwide. Selected patients with obstructive coronary artery disease benefit from revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Many (but not all) studies have demonstrated increased survival and greater freedom from adverse cardiovascular events after complete revascularization (CR) than after incomplete revascularization (ICR) in patients with multivessel disease. However, achieving CR after PCI or CABG surgery might not be feasible owing to patient comorbidities, anatomical factors, and technical or procedural considerations. These factors also mean that comparisons between CR and ICR are subject to multiple confounders and are difficult to understand or apply to real-world clinical practice. In this Review, we summarize and critically appraise the evidence linking various types of ICR to adverse outcomes in patients with multivessel disease and stable ischaemic heart disease, non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction, with or without cardiogenic shock. In addition, we provide practical recommendations for revascularization in patients with high-risk multivessel disease to optimize their long-term clinical outcomes and identify areas requiring future clinical investigation.
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Affiliation(s)
- Prakriti Gaba
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ziad A Ali
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Jeffrey W Moses
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, NY, USA. .,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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9
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Valensi P, Henry P, Boccara F, Cosson E, Prevost G, Emmerich J, Ernande L, Marcadet D, Mousseaux E, Rouzet F, Sultan A, Ferrières J, Vergès B, Van Belle E. Risk stratification and screening for coronary artery disease in asymptomatic patients with diabetes mellitus: Position paper of the French Society of Cardiology and the French-speaking Society of Diabetology. DIABETES & METABOLISM 2020; 47:101185. [PMID: 32846201 DOI: 10.1016/j.diabet.2020.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Paul Valensi
- Unit of Endocrinology Diabetology Nutrition, AP-HP, Jean Verdier hospital, CINFO, CRNH-IdF, Paris 13 University, Sorbonne Paris Cité, Bondy, France
| | - Patrick Henry
- Department of Cardiology, Inserm U942, Lariboisiere Hospital, Assistance Publique - Hôpitaux de Paris, University of Paris, Paris, France.
| | - Franck Boccara
- AP-HP, Hôpitaux de l'Est Parisien, Hôpital Saint-Antoine, Department of Cardiology, Sorbonne Université-Inserm UMR S_938, Centre de Recherche Saint-Antoine, Paris, France
| | - Emmanuel Cosson
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France; Paris 13 University, Sorbonne Paris Cité, UMR U557 Inserm/U11125 INRAE/CNAM/Université Paris13, Unité de Recherche Epidémiologique Nutritionnelle, Bobigny, France
| | - Gaetan Prevost
- Department of Endocrinology, Diabetes and Metabolic Diseases, Normandie Univ, UNIROUEN, Rouen University Hospital, Centre d'Investigation Clinique (CIC-CRB)-Inserm 1404, Rouen University Hospital, 76000 Rouen, France
| | - Joseph Emmerich
- Service de Médecine Vasculaire, Groupe Hospitalier Paris Saint-Joseph, Université de Paris, Inserm UMR1153-CRESS, 75674 Paris cedex 14, France
| | - Laura Ernande
- Service des explorations fonctionnelles, Hôpital Henri Mondor, AP-HP et Inserm U955, Université Paris-Est Créteil, France
| | - Dany Marcadet
- Centre Coeur et Santé Bernoulli - Cardiologie du sport et Réadaptation Cardiaque, 3, rue Bernoulli, 75008 Paris, France
| | - Elie Mousseaux
- Radiology Department, Hôpital Européen Georges Pompidou & Inserm U 970; Assistance Publique - Hôpitaux de Paris, University of Paris, French Society of Cardiovascular Imaging (SFICV), Paris, France
| | - François Rouzet
- Nuclear Medicine Department, Bichat Hospital, AP-HP Paris - Université de Paris, Laboratory for Vascular Translational Science, Inserm, UMR 1148, 75018 Paris, France
| | - Ariane Sultan
- Physiologie et Médecine Expérimentale du Coeur et des Muscles (PHYMEDEX), U1046 Inserm, UMR9214 CNRS, Université de Montpellier, 34295 Montpellier; Département Endocrinologie, Nutrition, Diabète, Equipe Nutrition, Diabète, CHRU Montpellier, 34090 Montpellier, France
| | - Jean Ferrières
- Department of Cardiology and UMR Inserm 1027, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Bruno Vergès
- Service Endocrinologie-Diabétologie, CHU Dijon - Inserm LNC-UMR 1231, Dijon, France
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France; Inserm, U1011, Institut Pasteur de Lille, EGID, Lille, France; Department of Medicine, Université de Lille, Lille, France
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10
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Wierzbowska-Drabik K, Trzos E, Kurpesa M, Rechcinski T, Miskowiec D, Cieslik-Guerra U, Uznanska-Loch B, Sobczak M, Kasprzak JD. Diabetes as an independent predictor of left ventricular longitudinal strain reduction at rest and during dobutamine stress test in patients with significant coronary artery disease. Eur Heart J Cardiovasc Imaging 2019; 19:1276-1286. [PMID: 29236974 DOI: 10.1093/ehjci/jex315] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
Aims Diabetes (DM) is a strong cardiovascular risk factor modifying also the left ventricular (LV) function that may be objectively assessed with echocardiographic strain analysis. Although the impact of isolated DM on myocardial deformation has been already studied, few data concern diabetics with coronary artery disease (CAD), especially in all stages of dobutamine stress echocardiography (DSE). We compared LV systolic function during DSE in CAD with and without DM using state-of-the art speckle-tracking quantification and assessed the impact of DM on LV systolic strain. Methods and results DSE was performed in 250 patients with angina who afterwards had coronarography with ≥50% stenosis in the left main artery and ≥70% in other arteries considered as significant. In this analysis, we included 127 patients with confirmed CAD: 42 with DM [DM(+); mean age 64 ± 9 years] and 85 patients without DM [DM(-); mean age 63 ± 9 years]. The severity of CAD and LV ejection fraction (EF) were similar in both groups. Global and regional LV peak systolic longitudinal strain (PSLS) revealed in all DSE phases lower values in DM(+) group: 14.5 ± 3.6% vs. 17.4 ± 4.0% at rest; P = 0.0001, 13.8 ± 3.9% vs. 16.7 ± 4.0% at peak stress; P = 0.0002, and 14.2 ± 3.1% vs. 15.5 ± 3.5% at recovery; P = 0.0432 for global parameters, although dobutamine challenge did not enhance further resting differences. LV EF, body surface area, and diabetes were independent predictors for strain in 16-variable model (R2 = 0, 51, P < 0.001). Conclusion PSLS although diminished in both groups with CAD was lower in diabetics at all DSE stages, and DM was an independent predictor of this impairment. However, the dobutamine challenge did not deepen the resting differences, suggesting that the direct impact of coronary stenoses effaces the influence of DM during DSE. The comparison with our previous data revealed synergistic, detrimental effect of coexisting CAD and DM on myocardial strain.
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Affiliation(s)
| | - Ewa Trzos
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
| | - Malgorzata Kurpesa
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
| | - Tomasz Rechcinski
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
| | - Dawid Miskowiec
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
| | - Urszula Cieslik-Guerra
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
| | - Barbara Uznanska-Loch
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
| | - Maria Sobczak
- Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, Lodz, Poland
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11
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Sicari R, Cortigiani L, Arystan AZ, Fettser DV. [The Clinical use of Stress Echocardiography in Ischemic Heart Disease Cardiovascular Ultrasound (2017)15:7. Translation authors: Arystan A.Zh., Fettser D.V.]. ACTA ACUST UNITED AC 2019; 59:78-96. [PMID: 30990145 DOI: 10.18087/cardio.2019.3.10244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 04/13/2019] [Indexed: 01/08/2023]
Abstract
Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows detecting myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependence on operator expertise, the lack of outcome data (a widespread problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.
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Affiliation(s)
| | | | - A Zh Arystan
- Medical Centre Hospital of President's Affairs Administration of the RK, Astana
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12
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Gaibazzi N. Stress Echocardiography: Need to Optimize its Appropriate Use in Suspected Angina and a Review of Available Additional Tools for its Clinical Application in 2018: First do no Harm! Second do it at the Highest Possible Accuracy. J Cardiovasc Echogr 2018; 28:154-159. [PMID: 30306018 PMCID: PMC6172890 DOI: 10.4103/jcecho.jcecho_16_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
There is a need to reassess the most appropriate indications for stress echocardiography in the current era, in patients with suspect or known coronary artery disease (CAD), and also the most helpful additional parameters that can be easily calculated in clinical practice to increase the known suboptimal sensitivity for obstructive CAD of this test. The current review tries to clarify what is and what should be the proper role for functional testing in general, but specifically regarding modern stress echocardiography in the current practice, for suspected CAD and/or atypical chest pain. Few candidate additional parameters beyond wall motion assessment are here suggested to improve diagnostic accuracy of stress echocardiography, and pertinent literature is briefly reviewed, together with a more personal view of the author regarding the characteristics of each parameter, as far as ease of acquisition, cost, and true diagnostic or prognostic clinical usefulness are concerned. The reviewed additional parameters, which can be acquired during stress echocardiography, are Doppler coronary flow reserve in the left anterior descending artery, cardiac calcium score, global longitudinal strain, ventricular elastance, and contrast myocardial perfusion. Each of them finds a potential place in the current practice or may find a place in the future practice of stress echocardiography.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Parma, Italy
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13
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Chilton R, Lin C, Gallegos KM, Pham S. Myocardial considerations in type 2 diabetes: 2018. J Diabetes 2018; 10:784-788. [PMID: 30033584 DOI: 10.1111/1753-0407.12788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
| | - Charles Lin
- UT Health San Antonio, San Antonio, Texas, USA
| | | | - Son Pham
- UT Health San Antonio, San Antonio, Texas, USA
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Philouze C, Obert P, Nottin S, Benamor A, Barthez O, Aboukhoudir F. Dobutamine Stress Echocardiography Unmasks Early Left Ventricular Dysfunction in Asymptomatic Patients with Uncomplicated Type 2 Diabetes: A Comprehensive Two-Dimensional Speckle-Tracking Imaging Study. J Am Soc Echocardiogr 2018. [PMID: 29526563 DOI: 10.1016/j.echo.2017.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Discrepancies are present in the literature on resting myocardial mechanics in patients with uncomplicated type 2 diabetes mellitus (T2DM). Data are noticeably sparse regarding circumferential function and torsional mechanics. Resting deformation imaging may not be sensitive enough to detect subtle dysfunctions. The aim of this study was thus to comprehensively evaluate myocardial mechanics in patients with T2DM at rest and to investigate whether dobutamine stress echocardiography could unmask functional alterations that would remain otherwise subtle at rest. METHODS Forty-four patients with T2DM and 35 healthy control subjects of similar age and sex were prospectively recruited. After conventional echocardiography, myocardial mechanics was evaluated at rest and during low-dose dobutamine stress echocardiography (target heart rate, 110 beats/min). RESULTS Patients with T2DM presented with altered global diastolic function but preserved systolic function. Deformation imaging indexes were similar between groups at rest, but significant differences were noticed under dobutamine infusion for longitudinal strain (-21.2 ± 2.4% vs -24.2 ± 2.5%, P < .001), circumferential strain (apex, -32.3 ± 5.3% vs -36.3 ± 5.3%, P = .002; papillary muscle, -25.6 ± 3.2% vs -28.0 ± 3.6%, P = .001; base, -23.2 ± 3.6% vs -25.3 ± 3.8%, P = .03), apical (11.2 ± 4.4° vs 14.1 ± 6.3°, P = .020) and basal (-12.2 ± 3.3° vs -14.3 ± 3.9°, P = .021) rotation, and twist (21.9 ± 5.9° vs 26.8 ± 8.3°, P = .007). Multivariate analysis identified epicardial fat, dyslipidemia, and fasting glycaemia as significant contributors to the changes from rest to dobutamine. CONCLUSIONS These findings demonstrate the usefulness of dobutamine stress echocardiography in establishing impairments in myocardial mechanics in patients with uncomplicated T2DM. Systemic metabolic disturbances and epicardial fat act as the main contributors to the blunted response to dobutamine stress in these patients.
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Affiliation(s)
- Clothilde Philouze
- EA4278 LaPEC, Laboratory of Cardiovascular Pharm-Ecology, Avignon University, Avignon, France
| | - Philippe Obert
- EA4278 LaPEC, Laboratory of Cardiovascular Pharm-Ecology, Avignon University, Avignon, France
| | - Stéphane Nottin
- EA4278 LaPEC, Laboratory of Cardiovascular Pharm-Ecology, Avignon University, Avignon, France
| | - Asma Benamor
- EA4278 LaPEC, Laboratory of Cardiovascular Pharm-Ecology, Avignon University, Avignon, France
| | - Olivier Barthez
- Cardiology Department, Duffaut Hospital Center, Avignon, France
| | - Falah Aboukhoudir
- EA4278 LaPEC, Laboratory of Cardiovascular Pharm-Ecology, Avignon University, Avignon, France; Cardiology Department, Duffaut Hospital Center, Avignon, France.
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15
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Gaibazzi N, Pastorini G, Biagi A, Tafuni F, Buffa C, Garibaldi S, Boffetti F, Benatti G. Equivocal tests after contrast stress-echocardiography compared with invasive coronary angiography or with CT angiography: CT calcium score in mildly positive tests may spare unnecessary coronary angiograms. Cardiovasc Ultrasound 2018; 16:3. [PMID: 29402323 PMCID: PMC5800005 DOI: 10.1186/s12947-017-0119-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 12/19/2017] [Indexed: 11/13/2022] Open
Abstract
Background Imaging stress tests are not ideally accurate to predict anatomically obstructive CAD, leading to a non-trivial rate of unnecessary iCA. This may depend on the threshold used to indicate iCA, and maybe CTA or, one step earlier, CT calcium score could spare most unnecessary iCA in only mildly positive cSE. We assessed the diagnostic accuracy of contrast stress-echocardiography (cSE) in comparison with invasive coronary angiography (iCA), and CT angiography (CTA) only in case of equivocal tests, to find hints helping reduce falsely positive cSE in the suspicion of coronary artery disease (CAD). Methods Patients who were indicated cSE for suspected CAD between 2012 and 2016, who also underwent iCA were selected and diagnostic results compared. A second group, specifically with equivocal cSE who underwent CTA was also analyzed. Results 137 subjects with equivocal cSE and CTA and 314 with cSE (any result) and iCA were selected. In the CTA-equivocal cSE group, an Agatston score < 105 and a coronary flow reserve (CFR-LAD) <1.7 had very high negative predictive value (99%, 92% respectively) to exclude obstructive CAD. The Agatston score was the most significant incremental predictor of CAD beyond clinical variables (chi square 31 to 47, p < 0.001). In the iCA group a more-than-mild reversible wall motion abnormality (WMA) demonstrated high positive predictive value for CAD (89%), while CFR-LAD appeared less useful. More-than-mild reversible WMA was the most significant predictor of CAD beyond clinical variables (chi square 37.5 to 56, p < 0.001). Conclusions Our data suggest iCA should be indicated only for more-than-mild reversible WMA at cSE, due to the very high positive predictive value for CAD of this finding, while mildly positive tests should be shifted to non-invasive CT, with CTA performed only for coronary calcium Agatston score > 100, since lower scores demonstrated very high negative predictive value for CAD, not justifying proceeding to CTA and even less to iCA.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy.
| | - Guido Pastorini
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
| | - Andrea Biagi
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
| | - Francesco Tafuni
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
| | - Claudia Buffa
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
| | - Silvia Garibaldi
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
| | - Francesca Boffetti
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
| | - Giorgio Benatti
- Department of Cardiology, Parma University Hospital, Via Gramsci 14, 43123, Parma, Italy
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16
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Keller K, Stelzer K, Geyer M, Münzel T, Ostad MA. Gender differences in bicycle exercise stress echocardiography testing. Artery Res 2018. [DOI: 10.1016/j.artres.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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O'Driscoll JM, Gargallo-Fernandez P, Araco M, Perez-Lopez M, Sharma R. Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography. Int J Cardiovasc Imaging 2017; 33:1711-1721. [PMID: 28685313 PMCID: PMC5682847 DOI: 10.1007/s10554-017-1163-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/08/2017] [Indexed: 12/22/2022]
Abstract
A number of parameters recorded during dobutamine stress echocardiography (DSE) are associated with worse outcome. However, the relative importance of baseline mitral regurgitation (MR) is unknown. The aim of this study was to assess the prevalence and associated implications of functional MR with long-term mortality in a large cohort of patients referred for DSE. 6745 patients (mean age 64.9 ± 12.2 years) were studied. Demographic, baseline and peak DSE data were collected. All-cause mortality was retrospectively analyzed. DSE was successfully completed in all patients with no adverse outcomes. MR was present in 1019 (15.1%) patients. During a mean follow up of 5.1 ± 1.8 years, 1642 (24.3%) patients died and MR was significantly associated with increased all-cause mortality (p < 0.001). With Kaplan-Meier analysis, survival was significantly worse for patients with moderate and severe MR (p < 0.001). With multivariate Cox regression analysis, moderate and severe MR (HR 2.78; 95% CI 2.17-3.57 and HR 3.62; 95% CI 2.89-4.53, respectively) were independently associated with all-cause mortality. The addition of MR to C statistic models significantly improved discrimination. MR is associated with all-cause mortality and adds incremental prognostic information among patients referred for DSE. The presence of MR should be taken into account when evaluating the prognostic significance of DSE results.
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Affiliation(s)
- Jamie M O'Driscoll
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
- School of Human and Life Sciences, Canterbury Christ Church University, Kent, UK
| | - Paula Gargallo-Fernandez
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Marco Araco
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Manuel Perez-Lopez
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - Rajan Sharma
- Department of Cardiology, St George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK.
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18
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Sharma A, Sekaran NK, Coles A, Pagidipati NJ, Hoffmann U, Mark DB, Lee KL, Al-Khalidi HR, Lu MT, Pellikka PA, Truong QA, Douglas PS. Impact of Diabetes Mellitus on the Evaluation of Stable Chest Pain Patients: Insights From the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) Trial. J Am Heart Assoc 2017; 6:JAHA.117.007019. [PMID: 29089344 PMCID: PMC5721780 DOI: 10.1161/jaha.117.007019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The impact of diabetes mellitus on the clinical presentation and noninvasive test (NIT) results among stable outpatients presenting with symptoms suggestive of coronary artery disease (CAD) has not been well described. Methods and Results The PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial enrolled 10 003 patients with known diabetic status, of whom 8966 were tested as randomized and had interpretable NIT results (1908 with diabetes mellitus, 21%). Differences in symptoms and NIT results were evaluated using logistic regression. Patients with diabetes mellitus (versus without) were similar in age (median 61 versus 60 years) and sex (female 54% versus 52%), had a greater burden of cardiovascular comorbidities, and had a similar likelihood of nonchest pain symptoms (29% versus 27%). The Diamond‐Forrester/Coronary Artery Surgery Study score predicted that patients with diabetes mellitus (versus without) had similar likelihood of obstructive CAD (low 1.8% versus 2.7%; intermediate 92.3% versus 92.6%; high 5.9% versus 4.7%). Physicians estimated patients with diabetes mellitus to have a higher likelihood of obstructive CAD (low to very low: 28.3% versus 40.1%; intermediate 63.9% versus 55.9%; high to very high 7.8% versus 4.0%). Patients with diabetes mellitus (versus without) were more likely to have a positive NIT result (15% versus 11%; adjusted odds ratio, 1.23; P=0.01). Conclusions Stable chest pain patients with and without diabetes mellitus have similar presentation and pretest likelihood of obstructive CAD; however, physicians perceive that patients with diabetes mellitus have a higher pretest likelihood of obstructive CAD, an assessment supported by increased risk of a positive NIT. Further evaluation of diabetes mellitus's influence on CAD assessment is required. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01174550.
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Affiliation(s)
- Abhinav Sharma
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Nishant K Sekaran
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Adrian Coles
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Michael T Lu
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Quynh A Truong
- New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Abstract
PURPOSE OF REVIEW Stress echocardiography (SE) is a well-established technique for the diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). This review article summarizes the status of SE in CAD, including testing protocols, clinical efficacy and current use of newer technologies: myocardial perfusion, strain imaging, three-dimensional echocardiography and adjunctive carotid ultrasonography. RECENT FINDINGS Recent major findings in SE include the clinical value of myocardial perfusion imaging in multicentre studies, as well as when added to left ventricular (LV) wall motion assessment in clinical service. Additionally, SE has been shown to be more cost-effective than exercise ECG in patients with low-intermediate pre-test probability of CAD. Adjunctive atherosclerosis imaging by carotid ultrasonography (CU) to ischaemia testing by SE provides synergistic prognostic value, equivalent to hybrid imaging by PET-CT. Despite the development of newer and more expensive imaging modalities, SE remains the cornerstone for the assessment of CAD and has excellent clinical efficacy, is safe and is cost-effective.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK
| | - Roxy Senior
- Department of Cardiology, Northwick Park Hospital, Harrow, UK.
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK.
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20
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Cortigiani L, Carpeggiani C, Sicari R, Michelassi C, Bovenzi F, Picano E. Simple six-item clinical score improves risk prediction capability of stress echocardiography. Heart 2017; 104:760-766. [DOI: 10.1136/heartjnl-2017-312122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 11/04/2022] Open
Abstract
ObjectivesTo assess the value of a simple score integrating non-ischaemia-related variables in expanding the wall motion abnormalities risk power during stress echocardiography (SE).MethodsStudy includes 14 279 patients who underwent SE for evaluation of coronary artery disease. All-cause death was the end point. Patients were randomly divided into the modelling and validation group of equal size. In the modelling group, multivariate analysis was conducted using clinical, rest and SE data, and a score was obtained from the number of non-ischaemia-related independent prognostic predictors. The score prognostic capability was compared in both groups.ResultsDuring a median follow-up of 31 months, 1230 patients died: 622 (9%) in the modelling and 608 (9%) in the validation group (p=0.68). Independent predictors of mortality were ischaemia at SE (HR 1.77, 95% CI 1.49 to 2.12; p<0.0001) and six other parameters: age>65 years, wall motion at rest, diabetes, left bundle branch block, anti-ischaemic therapy and male sex. Risk score resulted prognostically effective in the modelling and validation groups, both with and without inducible ischaemia subset. When risk score was included in the multivariate analysis, besides ischaemia at SE it was the only independent predictor of mortality in the modelling (HR 1.70, 95% CI 1.60 to 1.82; p<0.0001), in the validation (HR 1.77, 95% CI 1.65 to 1.90; p<0.0001) and in the overall group (HR 1.73, 95% CI 1.66 to 1.82; p<0.0001).ConclusionsSimple clinical variables may be able to optimise SE risk stratification.
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21
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Kaya H, Kandemir O, Beton O, Kivrak T, Kurt R, Yilmaz M. Demonstration of ischemia in myocardial perfusion scintigraphy before coronary revascularization decreases acute coronary syndrome-related hospitalizations. World J Nucl Med 2017; 16:212-217. [PMID: 28670180 PMCID: PMC5460305 DOI: 10.4103/1450-1147.207279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In this study, we compared the patients who underwent coronary angiography (CAG), followed by revascularization by coronary artery stent implantation according to the CAG results without any evidence of ischemia with myocardial perfusion scintigraphy (MPS), and the patients who underwent revascularization by coronary artery stent implantation following the detection of ischemia in MPS before CAG in terms of the mortality and hospitalization due to acute coronary syndrome (ACS). Between January 2009 and January 2016, a total of 407 patients (52% males, 48% females; mean age: 66 ± 9 years; range: 40–85 years) who underwent CAG following diagnosis of stable angina and underwent coronary artery stenting were retrospectively analyzed. The patients were divided into two groups: Group 1 (n = 200) included those who had MPS before CAG and in whom ischemia was detected and stent was implanted, and Group 2 (n = 207) included those who had stent implantation according to the CAG results without prior MPS. The mean follow-up was 40 ± 18 months. Although there was no significant difference in the mortality rates between the groups, the rate of hospitalization due to ACS was significantly lower in Group 1 (P = 0.112 vs. P = 0.022, respectively). According to the multivariate Cox-regression analysis, demonstration of ischemia in MPS before revascularization, statin use, clopidogrel use, and higher high-density lipoprotein cholesterol levels were found to be associated with a reduced risk of ACS-related hospitalization, whereas the presence of diabetes mellitus and smoking was found to be associated with an increased risk of ACS-related hospitalization.
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Affiliation(s)
- Hakki Kaya
- Department of Cardiology, Cumhuriyet University Medical School, Sivas
| | - Ozan Kandemir
- Department of Nuclear Medicine, Sivas State Hospital, Sivas
| | - Osman Beton
- Department of Cardiology, Cumhuriyet University Medical School, Sivas
| | - Tarik Kivrak
- Department of Cardiology, Sivas State Hospital, Sivas
| | - Recep Kurt
- Department of Cardiology, Sivas State Hospital, Sivas
| | - Mehmet Yilmaz
- Department of Cardiology, Cumhuriyet University Medical School, Sivas
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22
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Gaibazzi N, Porter T, Lorenzoni V, Pontone G, De Santis D, De Rosa A, Guaricci AI. Effect of Coronary Revascularization on the Prognostic Value of Stress Myocardial Contrast Wall Motion and Perfusion Imaging. J Am Heart Assoc 2017; 6:JAHA.117.006202. [PMID: 28566297 PMCID: PMC5669203 DOI: 10.1161/jaha.117.006202] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The assessment of myocardial perfusion (MP) and wall motion (WM) using contrast dipyridamole echocardiography (cSE‐WMP) improves the sensitivity to detect coronary artery disease and the stratification of cardiac events, but its long‐term value for fatal and nonfatal ischemic cardiac events, also with respect to patients undergoing revascularization or not, remains to be determined. Methods and Results One‐thousand three‐hundred and twenty‐nine patients with suspect or known CAD who underwent cSE‐WMP were followed for a median 5.5 years. The independent prognostic value of cSE‐WMP regarding cardiac death or nonfatal myocardial infarction was related to stress WM and MP, rest ejection fraction, clinical risk factors, and medications. Patients revascularized after cSE‐WMP were separately analyzed to determine whether the procedure influenced outcome and whether this depends on cSE‐WMP results. A total of 125 cardiac fatal and nonfatal ischemic events (9.4%) occurred during the follow‐up (61 deaths, 64 myocardial infarctions). The 5‐year event rate with normal MP and WM was 5.9%, 9.9% with isolated MP defects (normal WM), and 15.5% with both MP and WM abnormalities. In patients not undergoing revascularization (n=1111), reversible MP defects added discrimination value over WM response and clinical factors/medication data (P=0.001), while in the cohort undergoing revascularization (n=218), cSE‐WMP results did not influence outcome. Conclusions cSE‐WMP, with both contrast MP and WM assessments, provides independent, incremental prognostic information regarding ischemic cardiac events at 5 years in patients with known or suspected coronary artery disease. Revascularization reduces cardiac events after an abnormal cSE‐WMP, resulting in outcomes not different from those in patients with normal cSE‐WMP.
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Sicari R, Cortigiani L. The clinical use of stress echocardiography in ischemic heart disease. Cardiovasc Ultrasound 2017; 15:7. [PMID: 28327159 PMCID: PMC5361820 DOI: 10.1186/s12947-017-0099-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/15/2017] [Indexed: 12/18/2022] Open
Abstract
Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows to detect myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependance on operator expertise, the lack of outcome data (a widesperad problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.
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Affiliation(s)
- Rosa Sicari
- CNR, Institute of Clinical Physiology, Via G. Moruzzi, 1, 56124, Pisa, Italy.
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24
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Dual-Imaging Stress Echocardiography for Prognostic Assessment of High-Risk Asymptomatic Patients with Diabetes Mellitus. J Am Soc Echocardiogr 2017; 30:149-158. [DOI: 10.1016/j.echo.2016.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Indexed: 12/16/2022]
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25
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Sicari R. Stress echocardiography: no more challenges! Eur Heart J Cardiovasc Imaging 2016:jew225. [DOI: 10.1093/ehjci/jew225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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26
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Papachristidis A, Roper D, Cassar Demarco D, Tsironis I, Papitsas M, Byrne J, Alfakih K, Monaghan MJ. The prognostic role of stress echocardiography in a contemporary population and the clinical significance of limited apical ischaemia. Echo Res Pract 2016; 3:105-113. [PMID: 27872150 PMCID: PMC5184777 DOI: 10.1530/erp-16-0033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In this study, we aim to reassess the prognostic value of stress echocardiography (SE) in a contemporary population and to evaluate the clinical significance of limited apical ischaemia, which has not been previously studied. METHODS We included 880 patients who underwent SE. Follow-up data with regards to MACCE (cardiac death, myocardial infarction, any repeat revascularisation and cerebrovascular accident) were collected over 12 months after the SE. Mortality data were recorded over 27.02 ± 4.6 months (5.5-34.2 months). We sought to investigate the predictors of MACCE and all-cause mortality. RESULTS In a multivariable analysis, only the positive result of SE was predictive of MACCE (HR, 3.71; P = 0.012). The positive SE group was divided into 2 subgroups: (a) inducible ischaemia limited to the apical segments ('apical ischaemia') and (b) ischaemia in any other segments with or without apical involvement ('other positive'). The subgroup of patients with apical ischaemia had a significantly worse outcome compared to the patients with a negative SE (HR, 3.68; P = 0.041) but a similar outcome to the 'other positive' subgroup. However, when investigated with invasive coronary angiography, the prevalence of coronary artery disease (CAD) and their rate of revascularisation was considerably lower. Only age (HR, 1.07; P < 0.001) was correlated with all-cause mortality. CONCLUSION SE remains a strong predictor of patients' outcome in a contemporary population. A positive SE result was the only predictor of 12-month MACCE. The subgroup of patients with limited apical ischaemia have similar outcome to patients with ischaemia in other segments despite a lower prevalence of CAD and a lower revascularisation rate.
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Affiliation(s)
| | - Damian Roper
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Daniela Cassar Demarco
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ioannis Tsironis
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michael Papitsas
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jonathan Byrne
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Khaled Alfakih
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Lewisham Healthcare NHS Trust, London, United Kingdom
| | - Mark J Monaghan
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Keller K, Stelzer K, Munzel T, Ostad MA. Hypertension is strongly associated with false-positive bicycle exercise stress echocardiography testing results. Blood Press 2016; 25:351-359. [PMID: 27163258 DOI: 10.1080/08037051.2016.1182419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Exercise echocardiography is a reliable routine test in patients with known or suspected coronary artery disease. However, in ∼15% of all patients, stress echocardiography leads to false-positive stress echocardiography results. We aimed to investigate the impact of hypertension on stress echocardiographic results. METHODS We performed a retrospective study of patients with suspected or known stable coronary artery disease who underwent a bicycle exercise stress echocardiography. Patients with false-positive stress results were compared with those with appropriate results. RESULTS 126 patients with suspected or known coronary artery disease were included in this retrospective study. 23 patients showed false-positive stress echocardiography results. Beside comparable age, gender distribution and coronary artery status, hypertension was more prevalent in patients with false-positive stress results (95.7% vs. 67.0%, p = 0.0410). Exercise peak load revealed a borderline-significance with lower loads in patients with false-positive results (100.0 (IQR 75.0/137.5) vs. 125.0 (100.0/150.0) W, p = 0.0601). Patients with false-positive stress results showed higher systolic (2.05 ± 0.69 vs. 1.67 ± 0.39 mmHg/W, p = 0.0193) and diastolic (1.03 ± 0.38 vs. 0.80 ± 0.28 mmHg/W, p = 0.0165) peak blood pressure (BP) per wattage. In a multivariate logistic regression test, hypertension (OR 17.6 [CI 95% 1.9-162.2], p = 0.0115), and systolic (OR 4.12 [1.56-10.89], p = 0.00430) and diastolic (OR 13.74 [2.46-76.83], p = 0.00285) peak BP per wattage, were associated with false-positive exercise results. ROC analysis for systolic and diastolic peak BP levels per wattage showed optimal cut-off values of 1.935mmHg/W and 0.823mmHg/W, indicating false-positive exercise echocardiographic results with AUCs of 0.660 and 0.664, respectively. CONCLUSIONS Hypertension is a risk factor for false-positive stress exercise echocardiographic results in patients with known or suspected coronary artery disease. Presence of hypertension was associated with 17.6-fold elevated risk of false-positive results.
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Affiliation(s)
- Karsten Keller
- a Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Kathrin Stelzer
- b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Thomas Munzel
- a Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,c German Center for Cardiovascular Research, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Mir Abolfazl Ostad
- b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
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Baldassarre LA, Raman SV, Min JK, Mieres JH, Gulati M, Wenger NK, Marwick TH, Bucciarelli-Ducci C, Bairey Merz CN, Itchhaporia D, Ferdinand KC, Pepine CJ, Walsh MN, Narula J, Shaw LJ. Noninvasive Imaging to Evaluate Women With Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2016; 9:421-35. [PMID: 27056162 PMCID: PMC5486953 DOI: 10.1016/j.jcmg.2016.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/18/2022]
Abstract
Declines in cardiovascular deaths have been dramatic for men but occur significantly less in women. Among patients with symptomatic ischemic heart disease (IHD), women experience relatively worse outcomes compared with their male counterparts. Evidence to date has failed to adequately explore unique female imaging targets and their correlative signs and symptoms of IHD as major determinants of IHD risk. We highlight sex-specific anatomic and functional differences in contemporary imaging and introduce imaging approaches that leverage refined targets that may improve IHD risk prediction and identify potential therapeutic strategies for symptomatic women.
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Affiliation(s)
| | - Subha V Raman
- The Ohio State University College of Medicine, Columbus, Ohio
| | - James K Min
- Weill Cornell Medical College, New York, New York
| | | | - Martha Gulati
- The University of Arizona College of Medicine, Tucson, Arizona
| | | | | | | | | | - Dipti Itchhaporia
- Hoag Memorial Hospital Presbyterian Hospital, Newport Beach, California
| | | | - Carl J Pepine
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia.
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Aggeli C, Felekos I, Angelis A, Toutouzas K, Tousoulis D. Dobutamine stress echo in diabetics: Changes in prognosis according to appropriateness criteria indication. Int J Cardiol 2016; 214:207-8. [PMID: 27064644 DOI: 10.1016/j.ijcard.2016.03.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/20/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Constantina Aggeli
- 1st Cardiology Department, Hippokration Hospital, Athens Medical School, Greece.
| | - Ioannis Felekos
- 1st Cardiology Department, Hippokration Hospital, Athens Medical School, Greece
| | - Athanasios Angelis
- 1st Cardiology Department, Hippokration Hospital, Athens Medical School, Greece
| | | | - Dimitris Tousoulis
- 1st Cardiology Department, Hippokration Hospital, Athens Medical School, Greece
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Stone GW, Hochman JS, Williams DO, Boden WE, Ferguson TB, Harrington RA, Maron DJ. Medical Therapy With Versus Without Revascularization in Stable Patients With Moderate and Severe Ischemia: The Case for Community Equipoise. J Am Coll Cardiol 2016; 67:81-99. [PMID: 26616030 PMCID: PMC5545795 DOI: 10.1016/j.jacc.2015.09.056] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/10/2015] [Accepted: 09/22/2015] [Indexed: 12/21/2022]
Abstract
All patients with stable ischemic heart disease (SIHD) should be managed with guideline-directed medical therapy (GDMT), which reduces progression of atherosclerosis and prevents coronary thrombosis. Revascularization is also indicated in patients with SIHD and progressive or refractory symptoms, despite medical management. Whether a strategy of routine revascularization (with percutaneous coronary intervention or coronary artery bypass graft surgery as appropriate) plus GDMT reduces rates of death or myocardial infarction, or improves quality of life compared to an initial approach of GDMT alone in patients with substantial ischemia is uncertain. Opinions run strongly on both sides, and evidence may be used to support either approach. Careful review of the data demonstrates the limitations of our current knowledge, resulting in a state of community equipoise. The ongoing ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) is being performed to determine the optimal approach to managing patients with SIHD, moderate-to-severe ischemia, and symptoms that can be controlled medically. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Gregg W Stone
- Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York.
| | - Judith S Hochman
- Department of Medicine, Cardiovascular Clinical Research Center, New York University School of Medicine, New York, New York
| | - David O Williams
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - William E Boden
- Department of Medicine, Samuel S. Stratton VA Medical Center, Albany Medical Center and Albany Medical College, Albany, New York
| | - T Bruce Ferguson
- Department of Cardiovascular Sciences, East Carolina Heart Institute, East Carolina University, Greenville, North Carolina
| | - Robert A Harrington
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Petretta M, Acampa W, Daniele S, Zampella E, Assante R, Nappi C, Salvatore M, Cuocolo A. Long-Term Survival Benefit of Coronary Revascularization in Patients Undergoing Stress Myocardial Perfusion Imaging. Circ J 2015; 80:485-93. [PMID: 26686993 DOI: 10.1253/circj.cj-15-1093] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We assessed the relationship between clinical outcome and coronary revascularization according to stress-gated myocardial perfusion single-photon emission computed tomography (MPS) in an observational series of patients with suspected or known coronary artery disease (CAD), on long-term follow-up. METHODS AND RESULTS The study group consisted of 2,059 patients. During a median follow-up of 61 months, 184 events occurred (126 cardiac deaths and 58 non-fatal MI). The impact of revascularization during follow-up on event-free survival was evaluated using an extended Cox regression model, adjusting for potential clinical and MPS confounders. Revascularization was treated as a binary non-reversible time-dependent covariate. Predefined interactions tested were: (1) revascularization and summed difference score (SDS); (2) revascularization and post-stress left ventricular (LV) ejection fraction (EF); and (3) SDS and post-stress LVEF. Revascularization had a significant effect on event-free survival (adjusted HR, 0.19; P<0.001). Significant interactions were found between revascularization and SDS (P=0.045), and between LVEF and SDS (P=0.015). The protective effect of revascularization increased as SDS increased. For SDS <6 the reduction in HR was detectable only for reduced LVEF. CONCLUSIONS Both the degree of stress-induced ischemia and LVEF predict the effect of revascularization on outcome in patients with suspected or known CAD. The protective effect of revascularization appears to be greater in patients with severe ischemia and preserved LVEF.
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Affiliation(s)
- Mario Petretta
- Department of Translational Medical Sciences, University of Naples Federico II
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The Burden of Australian Indigenous Cardiac Disease and the Emerging Role of Cardiac Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9353-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Baroncini LAV, Borsoi R, Vidal MEB, Valente NJ, Veloso J, Pecoits Filho R. Assessment of dipyridamole stress echocardiography for risk stratification of diabetic patients. Cardiovasc Ultrasound 2015. [PMID: 26209102 PMCID: PMC4515011 DOI: 10.1186/s12947-015-0030-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite advances in medical therapy, cardiovascular disease, mainly coronary artery disease (CAD), remains the leading cause of mortality among patients with diabetes mellitus (DM). The objective of the present study was to assess the effectiveness of dipyridamole stress echocardiography in identify diabetic patients at high risk for cardiovascular events. METHODS Dipyridamole stress echocardiography was administered to 483 diabetic patients (294 women; mean age 63.41 ± 11.28 years) between July 2006 and December 2012. RESULTS Follow-up data were available for 264 patients (163 women; mean age 64.3 ± 10.5 years): 250 with a negative stress echocardiography and 14 with a positive stress echo. During a mean follow-up time of 18 ± 14 months, a cardiovascular event occurred in 18 (6.8%) patients, 12 (4.8%) in patients with a negative stress echo (n = 250) during a mean follow-up period of 20 ± 16 months and 6 (42%) in patients with positive stress echo (n = 14) during a mean follow-up of 13 ± 13 months. The positive and negative predictive values of stress echocardiography were 42% and 96% respectively. The accuracy value was 92%. A Cox regression model showed that CAD (hazard ratio [HR] 5.4, 95% confidence interval [CI] 1.9-15.4; p = 0.002) and positive stress echocardiography (HR 7.1, 95% CI 2.5-20.5; p < 0.001) were significant predictors of cardiovascular events. CONCLUSIONS For patients with diabetes, a negative dipyridamole stress echocardiogram predicts favorable outcome during the first year of follow-up. A new stress imaging test should be done after 12 months in diabetic patients.
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Affiliation(s)
- Liz Andréa Villela Baroncini
- Center of Health and Biological Sciences, Pontificia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Prado Velho, CEP: 80215-901, Curitiba, Paraná, Brazil.
| | - Rafael Borsoi
- Department of Internal Medicine, Medical School, Universidade Federal do Paraná, Rua XV de Novembro, 1299, Centro, CEP: 80060-000, Curitiba, Paraná, Brazil
| | - Maria Eugênia Bégué Vidal
- Medical School, Faculdade Evangélica, Rua Padre Anchieta, 2770, CEP: 80730-000, Curitiba, Paraná, Brazil
| | - Nathália Julim Valente
- Medical School, Faculdade Evangélica, Rua Padre Anchieta, 2770, CEP: 80730-000, Curitiba, Paraná, Brazil
| | - Juliana Veloso
- Pontificia Universidade Católica do Paraná, Curitiba, Brazil
| | - Roberto Pecoits Filho
- Center of Health and Biological Sciences, Pontificia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Prado Velho, CEP: 80215-901, Curitiba, Paraná, Brazil
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