The Diagnosis of Chronic Coronary Heart Disease

Competence of radiologists in cardiac CT and MR imaging in Europe: insights from the ESCR Registry

RATIONALE

To provide an overview of the current status of cardiac multimodality imaging practices in Europe and radiologist involvement using data from the European Society of Cardiovascular Radiology (ESCR) MRCT-registry.

MATERIALS AND METHODS

Numbers on cardiac CT and MRI examinations were extracted from the MRCT-registry of the ESCR, entered between January 2011 and October 2023 (n = 432,265). Data collection included the total/annual numbers of examinations, indications, complications, and reporting habits.

RESULTS

Thirty-two countries contributed to the MRCT-registry, including 29 European countries. Between 2011 and 2022, there was a 4.5-fold increase in annually submitted CT examinations, from 3368 to 15,267, and a 3.8-fold increase in MRI examinations, from 3445 to 13,183. The main indications for cardiac CT were suspected coronary artery disease (CAD) (59%) and transcatheter aortic valve replacement planning (21%). The number of patients with intermediate pretest probability who underwent CT for suspected CAD showed an increase from 61% in 2012 to 82% in 2022. The main MRI indications were suspected myocarditis (26%), CAD (21%), and suspected cardiomyopathy (19%). Adverse event rates were very low for CT (0.3%) and MRI (0.7%) examinations. Reporting of CT and MRI examinations was performed mainly by radiologists (respectively 76% and 71%) and, to a lesser degree, in consensus with non-radiologists (19% and 27%, respectively). The remaining examinations (4.9% CT and 1.7% MRI) were reported by non-radiological specialties or in separate readings of radiologists and non-radiologists.

CONCLUSIONS

Real-life data on cardiac imaging in Europe using the largest available MRCT-registry demonstrate a considerable increase in examinations over the past years, the vast majority of which are read by radiologists. These findings indicate that radiologists contribute to meeting the increasing demands of competent and effective care in cardiac imaging to a relevant extent.

CLINICAL RELEVANCE STATEMENT

The number of cardiac CT and MRI examinations has risen over the past years, and radiologists read the vast majority of these studies as recorded in the MRCT-registry.

KEY POINTS

• The number of cardiac imaging examinations is constantly increasing. • Radiologists play a central role in providing cardiac CT and MR imaging services to a large volume of patients. • Cardiac CT and MR imaging examinations performed and read by radiologists show a good safety profile.

Machine learning aided non-invasive diagnosis of coronary heart disease based on tongue features fusion

BACKGROUND

Coronary heart disease (CHD) is the first cause of death globally. Hypertension is considered to be the most important independent risk factor for CHD. Early and accurate diagnosis of CHD in patients with hypertension can plays a significant role in reducing the risk and harm of hypertension combined with CHD.

OBJECTIVE

To propose a non-invasive method for early diagnosis of coronary heart disease according to tongue image features with the help of machine learning techniques.

METHODS

We collected standard tongue images and extract features by Diagnosis Analysis System (TDAS) and ResNet-50. On the basis of these tongue features, a common machine learning method is used to customize the non-invasive CHD diagnosis algorithm based on tongue image.

RESULTS

Based on feature fusion, our algorithm has good performance. The results showed that the XGBoost model with fused features had the best performance with accuracy of 0.869, the AUC of 0.957, the AUPR of 0.961, the precision of 0.926, the recall of 0.806, and the F1-score of 0.862.

CONCLUSION

We provide a feasible, convenient, and non-invasive method for the diagnosis and large-scale screening of CHD. Tongue image information is a possible effective marker for the diagnosis of CHD.

Restrictions of VC and DLCO in relation to asbestos-related computed tomographic findings quantified by ICOERD-based parameters

BACKGROUND

Even almost 30 years after the ban on the use of asbestos in Germany, the effects of asbestos are still highly relevant in everyday clinical practice in occupational medicine. The aim of this study was to further investigate the significance of essential parameters of both pulmonary function diagnostics and imaging techniques (low-dose HR-TCT) for the prevention and early detection of asbestos-related morphological and functional lung changes.

METHODS

Data from spirometry, body plethysmography and diffusion capacity, as well as CT images of the thorax, were retrospectively studied from 72 patients examined between 2017 and 2019 at the Institute for Occupational and Maritime Medicine (ZfAM), Hamburg, Germany. The subjects were divided into four subgroups according to the presence of comorbidities (concomitant cardiac diseases, obstructive ventilatory disorder, pulmonary function pattern consistent with emphysema, and no other pulmonary or cardiac diseases). These subgroups were analysed in addition to the overall collective. The CT images were evaluated according to the International Classification of Occupational and Environmental Respiratory Diseases (ICOERD) with radiological expertise. In addition, some asbestos-related parameters were newly quantified, and corresponding scores were defined based on ICOERD. Statistical analysis included the use of correlations and fourfold tables with calculation of Spearman's rho (ρ), Cohen's κ, and accuracy.

RESULTS

Vital capacity (VC) is slightly reduced in the total collective compared to the normal population (mean 92% of predicted value), while diffusion capacity for CO (DLCO) shows predominantly pathological values, mean 70% of the respective predicted value. The CO transfer coefficient (DLCO/VA), which refers to alveolar volume (VA), also shows slightly decreased values (mean 87% pred.). Seventy-nine percent of patients (n = 57) had signs of pulmonary fibrosis on CT scans, and pleural plaques appeared in 58 of 72 patients (81%). Of the newly quantified additional parameters, particularly frequently described findings are subpleural curvilinear lines (SC, n = 39) and parenchymal bands (PB, n = 29). VC correlates well with the expression of pleural plaques (ρ = - 0.273, P < 0.05), and DLCO measures show a better correlation with fibrosis score (ρ = - 0.315, P < 0.01). A third, newly developed score, which includes the extent of pleural plaques and additional subpleural parameters instead of fibrosis parameters, shows significant correlations for both VC and DLCO (ρ = - 0.283, - 0.274, resp.; both P < 0.05).

DISCUSSION

The importance of spirometry (VC) and diffusion capacity measurement (DLCO) as essential diagnostic procedures for the early detection of asbestos-related changes ‒ also including patients with relevant concomitant cardiac or pulmonary diseases ‒ was confirmed. Significant and better correlations between lung function changes (VC and DLCO) and abnormal CT findings are seen when parenchymal bands (PB), subpleural curvilinear lines (SC), and rounded atelectasis (RA) are quantitatively included into the evaluation, in addition to assessing the extent of pleural plaques alone. Therefore, when assessing CT images according to ICOERD, these parameters should also be quantified.

Elevated blood urea nitrogen-to-creatinine ratio increased the risk of Coronary Artery Disease in patients living with type 2 diabetes mellitus

BACKGROUND

High Blood Urea Nitrogen (BUN) and high Serum Creatinine (SCr) levels are risk factors for Coronary Artery Disease (CAD). However, the relationship between the Blood Urea Nitrogen to Creatinine (BUN/SCr) ratio (UCR) and the risk of CAD in patients living with new-onset diabetes is unclear. This study aimed to examine the relationship between blood UCR and the risk of CAD in patients living with new-onset type 2 diabetes mellitus (T2DM).

METHODS

We analyzed the data from the cohort of 12,299 patients living with type 2 diabetes mellitus. Primary endpoints were the events of CAD. The ANOVA test (continuous indicators) and χ² test (categorical indicators) were used to assess the differences of baseline characteristics across the groups of UCR. In order to understand the correlation between variables, we performed correlation analysis on variables that have significant differences between CAD group and non-CAD group. Multivariate-adjusted Cox proportional hazard regression models were applied to estimate the association of the blood UCR with the risk of CAD in patients living with T2DM. The Kaplan-Meier survival function plotting and the log-rank test were used to evaluate the event-free survival according to the groups of UCR. The restricted cubic spline model was used to show the adjusted association between blood UCR and risk of CAD in patients living with T2DM.

RESULTS

During a median follow-up of 2.66 years, 1173 CAD were recorded with an event rate of 28.49 events per 1000 person-years. In multivariate-adjusted Cox regression models, elevated blood urea nitrogen to creatinine ratio (UCR) was associated with higher risk of CAD in patients living with T2DM [hazard ratio (HR), 1.782; 95% confidence interval (CI), 1.237-2.567]. The Kaplan-Meier survival curves indicated that the high group of UCR tended to have a lower event-free survival than the low group and medium group. There was a nonlinear trend toward increasing risk of CAD across the groups of UCR. And cubic spline function graph suggested that the influence of UCR level on HR for CAD increased significantly at UCR levels above 6.67.

CONCLUSIONS

An elevated UCR was significantly associated with an increased risk for CAD in patients living with T2DM.

Identification of Subclinical Microvascular Biomarkers in Coronary Heart Disease in Retinal Imaging

Purpose

Cardiovascular disease and foremost coronary heart disease (CHD) are the worldwide leading causes of death. The aim of this study was to use non-invasive, multimodel retinal imaging to define microvascular features in patients with and without coronary angiography (CA)-confirmed CHD.

Methods

In this prospective, cross-sectional pilot study we included adult patients who presented to a tertiary referral center for elective CA due to suspected CHD. All patients underwent widefield fundus photography for retinopathy grading. Optical coherence tomography angiography was used to measure vessel density (VD) of the individual capillary plexuses in 6 × 6-mm macular volume scans. Adaptive optics imaging was performed to assess the first-order arteriolar lumen diameter (LD), total diameter (TD), wall-to-lumen ratio (WLR), and wall cross-section area, as well as to qualitatively describe vessel morphology.

Results

Of the included 45 patients (13 females; 65 ± 10 years old), 27 were confirmed with CHD in elective CA. The most prevalent retinal vascular pathologies were arteriovenous nickings, focal arterial narrowings, and microaneurysms. VD in the superficial capillary plexus, deep capillary plexus, and choriocapillaris was lower in CHD patients, although the odds ratios were not significantly different from 1 (P = 0.06–0.92). Median arterial LD, TD, and WLR values were 98.3 µm (interquartile range [IQR] = 13.0), 122.9 µm (IQR = 17.6), and 0.26 µm (IQR = 0.07), respectively, with a trend toward a higher WLR in CHD patients.

Conclusions

In a cardiovascular risk population, high-resolution quantitative and qualitative microvascular phenotyping in the retina may provide valuable subclinical indicators for coronary artery impairment, although larger clinical trials are needed.

Translational Relevance

Subclinical retinal microvascular changes may serve as non-invasive, cost-effective biomarkers for risk stratification of patients with CHD.

Recent Trends in Artificial Intelligence-Assisted Coronary Atherosclerotic Plaque Characterization

Coronary artery disease is a major cause of morbidity and mortality worldwide. Its underlying histopathology is the atherosclerotic plaque, which comprises lipid, fibrous and—when chronic—calcium components. Intravascular ultrasound (IVUS) and intravascular optical coherence tomography (IVOCT) performed during invasive coronary angiography are reference standards for characterizing the atherosclerotic plaque. Fine image spatial resolution attainable with contemporary coronary computed tomographic angiography (CCTA) has enabled noninvasive plaque assessment, including identifying features associated with vulnerable plaques known to presage acute coronary events. Manual interpretation of IVUS, IVOCT and CCTA images demands scarce physician expertise and high time cost. This has motivated recent research into and development of artificial intelligence (AI)-assisted methods for image processing, feature extraction, plaque identification and characterization. We performed parallel searches of the medical and technical literature from 1995 to 2021 focusing respectively on human plaque characterization using various imaging modalities and the use of AI-assisted computer aided diagnosis (CAD) to detect and classify atherosclerotic plaques, including their composition and the presence of high-risk features denoting vulnerable plaques. A total of 122 publications were selected for evaluation and the analysis was summarized in terms of data sources, methods—machine versus deep learning—and performance metrics. Trends in AI-assisted plaque characterization are detailed and prospective research challenges discussed. Future directions for the development of accurate and efficient CAD systems to characterize plaque noninvasively using CCTA are proposed.

The Impact of Cardiovascular Rehabilitation on Psychophysiological Stress, Personality and Tryptophan Metabolism: A Randomized Pilot Feasibility Study

Multicomponent cardiac rehabilitation (CR) is a secondary prevention strategy for cardiac patients to tackle stress and psychosocial wellbeing. However, there is a lack of data on its psychoneuroimmunological effects and of biomarkers to determine individual risk and to develop treatment strategies. We conducted a pilot randomized controlled trial (RCT) to investigate the feasibility of deriving psychophysiological stress markers in patients with cardiovascular diseases. Thirty individuals with cardiovascular disease (mean age 58.8 years; 23.3% female) were enrolled and randomized into three treatment groups: standard rehabilitation, yoga, or transcendental meditation (TM). Depression, anxiety, sleep, stress perception, personality functioning, hair cortisol, serum tryptophan, kynurenine and neopterin concentrations were estimated at baseline and after a four-week intervention. Hair cortisol levels decreased significantly after rehabilitation in all groups (F = 15.98, p < 0.001). In addition, personality functioning improved in all patients over time. Participants with impairments in personality functioning showed a positive correlation with baseline neopterin that did not remain significant after Bonferroni correction. Concentrations of serum tryptophan and its metabolite kynurenine did not change significantly. This pilot RCT provides preliminary evidence of multicomponent CR leading to stabilization of hair cortisol levels and improved psychophysiological wellbeing and personality functioning. Impairments in personality functioning were correlated with neopterin levels, which may impact the symptomatology and outcome.

Risk factors for acute pulmonary embolism in patients with off-pump coronary artery bypass grafting: implications for nursing

Objective

Acute pulmonary embolism (APE) is a serious complication after off-pump coronary artery bypass grafting (OPCABG). We aimed to analyze the risk factors for APE in patients with OPCABG.

Methods

In this retrospective, observational study, patients with OPCABG who were treated in our hospital from 1 January 2018 to 31 March 2020 were included. The basic characteristics of patients and results of preoperative laboratory examinations were collected and analyzed.

Results

A total of 707 patients with OPCABG were included and the incidence of APE was 3.21%. Left ventricular ejection fraction (LVEF), a history of smoking, number of bypass grafting, duration of surgery, and age were significant risk factors for APE in patients with OPCABG. The areas under the curves of LVEF, number of bypass grafting, duration of surgery, and age were 0.773, 0.759, 0.738, and 0.723, respectively. The cutoff values of LVEF, number of bypass grafting, duration of surgery, and age were 59.84, 3.18, 237.42, and 73.28, respectively.

Conclusions

LVEF, a history of smoking, number of bypass grafting, duration of surgery, and age may be risk factors for APE in patients with OPCABG. Early measures should be taken to target these risks to prevent APE.

Change in prevalence of Coronary Heart Disease and its risk between 1991-94 to 2010-12 among rural and urban population of National Capital Region, Delhi

OBJECTIVES

We aimed to measure the change in prevalence of Coronary Heart Disease (CHD) and Cardiovascular Diseases (CVDs) risk among those aged 35-64 years in urban and rural areas of National Capital Region (NCR) of Delhi, between 1991-1994 (survey 1) and 2010-2012 (survey 2).

METHODS

Both surveys used similar sampling methodology and mean ages of participants were similar. A total of 3048 and 2052 subjects were studied in urban Delhi and 2487 and 1917 participants recruited from rural Ballabgarh in survey 1 and in survey 2 respectively. CHD was diagnosed based on a Minnesota coded ECG and Rose angina questionnaire. Data on behavioural, physical, clinical and biochemical parameters were collected using standard methods. CVD Risk of participants was calculated using the gender specific Framingham risk equation.

RESULTS

The age and sex standardised prevalence of CHD in urban Delhi increased from 10.3% (95% CI: 9.2-11.4) to 14.1% (95% CI: 12.6-15.6) between the two surveys as compared to an increase from 6.0% (95% CI: 5.0-6.9) to 7.4% (95% CI: 6.3-8.6) in rural Ballabgarh. The highest increase in the prevalence of CHD was reported among urban women (10.1% to 16.6%).The proportion of population with high 10-year CVD risk increased to 4.1% from 1.2% in rural areas as compared to 4.8% from 2.5% in urban areas.

CONCLUSIONS

The CHD and CVD risk has increased over 20 years period in and around Delhi and the increase was more in rural population and women, traditionally considered to be at low risk.