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Peper J, Becker LM, Bruning TA, Budde RPJ, van Dockum WG, Frederix GWJ, Habets J, Henriques JPS, Houthuizen P, Mohamed Hoesein FAA, Planken RN, Voskuil M, Bots ML, Leiner T, Swaans MJ. Rationale and design of the iCORONARY trial: improving the cost-effectiveness of coronary artery disease diagnosis. Neth Heart J 2023; 31:150-156. [PMID: 36720801 PMCID: PMC10033793 DOI: 10.1007/s12471-023-01758-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In patients with stable coronary artery disease (CAD), revascularisation decisions are based mainly on the visual grading of the severity of coronary stenosis on invasive coronary angiography (ICA). However, invasive fractional flow reserve (FFR) is the current standard to determine the haemodynamic significance of coronary stenosis. Non-invasive and less-invasive imaging techniques such as computed-tomography-derived FFR (FFR-CT) and angiography-derived FFR (QFR) combine both anatomical and functional information in complex algorithms to calculate FFR. TRIAL DESIGN The iCORONARY trial is a prospective, multicentre, non-inferiority randomised controlled trial (RCT) with a blinded endpoint evaluation. It investigates the costs, effects and outcomes of different diagnostic strategies to evaluate the presence of CAD and the need for revascularisation in patients with stable angina pectoris who undergo coronary computed tomography angiography. Those with a Coronary Artery Disease-Reporting and Data System (CAD-RADS) score between 0-2 and 5 will be included in a prospective registry, whereas patients with CAD-RADS 3 or 4A will be enrolled in the RCT. The RCT consists of three randomised groups: (1) FFR-CT-guided strategy, (2) QFR-guided strategy or (3) standard of care including ICA and invasive pressure measurements for all intermediate stenoses. The primary endpoint will be the occurrence of major adverse cardiac events (death, myocardial infarction and repeat revascularisation) at 1 year. CLINICALTRIALS gov-identifier: NCT04939207. CONCLUSION The iCORONARY trial will assess whether a strategy of FFR-CT or QFR is non-inferior to invasive angiography to guide the need for revascularisation in patients with stable CAD. Non-inferiority to the standard of care implies that these techniques are attractive, less-invasive alternatives to current diagnostic pathways.
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Affiliation(s)
- J Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - L M Becker
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - T A Bruning
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - R P J Budde
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - W G van Dockum
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - G W J Frederix
- Department of Public Health, Healthcare Innovation and Evaluation and Medical Humanities, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J Habets
- Department of Radiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J P S Henriques
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - P Houthuizen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - F A A Mohamed Hoesein
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - R N Planken
- Department of Radiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M L Bots
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - T Leiner
- Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Radiology, Mayo Clinic Hospital, Rochester, United States of America
| | - M J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Peper J, Becker LM, Swaans MJ. Apples and oranges in coronary artery disease diagnostics. Kardiol Pol 2023; 81:218-220. [PMID: 36791422 DOI: 10.33963/kp.a2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 02/17/2023]
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Peper J, Becker LM, Van Den Berg H, Bor WL, Brouwer J, Nijenhuis VJ, Van Ginkel DJ, Rensing BMJW, Timmer L, Ten Berg JM, Leiner T, Swaans MJ. Diagnostic performance of coronary CTA and CT-FFR for the detection of coronary artery disease in routine TAVI work-up. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
To assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVI.
Background
Work-up for transcatheter aortic valve implantation (TAVI) currently utilizes computed tomography (CT) to evaluate annulus diameter and peripheral vascular access, plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of Coronary CT Angiography (CCTA). Prior studies found improvement of the diagnostic accuracy of CCTA by use of CT derived fractional flow reserve (CT-FFR).
Methods
Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI work-up between 2015–2019 were included in this cross-sectional study. All patients underwent CCTA and ICA within 3 months and diagnostic performance of both CCTA and CT-FFR were assessed using ICA as reference.
Results
Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis at ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per-patient were 76.9%, 64.5%, 34.0%, 92.1% and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0% and 87.6% for CT-FFR. The area under the receiver-operating characteristic-curve significantly differ between CCTA and CT-FFR (0.84 versus 0.90 p=0.02). A CT-FFR guided approach could avoid ICA in 57.1% versus 43.6% using CCTA.
Conclusions
CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided It has the potential to be integrated in the current clinical work-up for TAVI for diagnosing stable CAD requiring treatment.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Peper
- St Antonius Hospital , Nieuwegein , The Netherlands
| | - L M Becker
- St Antonius Hospital , Nieuwegein , The Netherlands
| | | | - W L Bor
- St Antonius Hospital , Nieuwegein , The Netherlands
| | - J Brouwer
- St Antonius Hospital , Nieuwegein , The Netherlands
| | | | | | | | - L Timmer
- St Antonius Hospital , Nieuwegein , The Netherlands
| | - J M Ten Berg
- St Antonius Hospital , Nieuwegein , The Netherlands
| | - T Leiner
- Mayo Clinic , Rochester , United States of America
| | - M J Swaans
- St Antonius Hospital , Nieuwegein , The Netherlands
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Davis RL, Shrimpton AE, Holohan PD, Bradshaw C, Feiglin D, Collins GH, Sonderegger P, Kinter J, Becker LM, Lacbawan F, Krasnewich D, Muenke M, Lawrence DA, Yerby MS, Shaw CM, Gooptu B, Elliott PR, Finch JT, Carrell RW, Lomas DA. Familial dementia caused by polymerization of mutant neuroserpin. Nature 1999; 401:376-9. [PMID: 10517635 DOI: 10.1038/43894] [Citation(s) in RCA: 184] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aberrant protein processing with tissue deposition is associated with many common neurodegenerative disorders; however, the complex interplay of genetic and environmental factors has made it difficult to decipher the sequence of events linking protein aggregation with clinical disease. Substantial progress has been made toward understanding the pathophysiology of prototypical conformational diseases and protein polymerization in the superfamily of serine proteinase inhibitors (serpins). Here we describe a new disease, familial encephalopathy with neuroserpin inclusion bodies, characterized clinically as an autosomal dominantly inherited dementia, histologically by unique neuronal inclusion bodies and biochemically by polymers of the neuron-specific serpin, neuroserpin. We report the cosegregation of point mutations in the neuroserpin gene (PI12) with the disease in two families. The significance of one mutation, S49P, is evident from its homology to a previously described serpin mutations, whereas that of the other, S52R, is predicted by modelling of the serpin template. Our findings provide a molecular mechanism for a familial dementia and imply that inhibitors of protein polymerization may be effective therapies for this disorder and perhaps for other more common neurodegenerative diseases.
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Affiliation(s)
- R L Davis
- Department of Clinical Pathology, State University of New York Health Science Center, Syracuse 13210, USA
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Becker LM, Zuker RM. Vascularized fibular epiphyseal transplantation for limb salvage following bone tumour excision. Plast Surg (Oakv) 1999. [DOI: 10.4172/plastic-surgery.1000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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