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Kuronuma K, Miller RJH, Wei CC, Singh A, Lemley MH, Van Kriekinge SD, Kavanagh PB, Gransar H, Han D, Hayes SW, Thomson L, Dey D, Friedman JD, Berman DS, Slomka PJ. Downward myocardial creep during stress PET imaging is inversely associated with mortality. Eur J Nucl Med Mol Imaging 2024; 51:1622-1631. [PMID: 38253908 PMCID: PMC11042981 DOI: 10.1007/s00259-024-06611-2] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024]
Abstract
PURPOSE The myocardial creep is a phenomenon in which the heart moves from its original position during stress-dynamic PET myocardial perfusion imaging (MPI) that can confound myocardial blood flow measurements. Therefore, myocardial motion correction is important to obtain reliable myocardial flow quantification. However, the clinical importance of the magnitude of myocardial creep has not been explored. We aimed to explore the prognostic value of myocardial creep quantified by an automated motion correction algorithm beyond traditional PET-MPI imaging variables. METHODS Consecutive patients undergoing regadenoson rest-stress [82Rb]Cl PET-MPI were included. A newly developed 3D motion correction algorithm quantified myocardial creep, the maximum motion at stress during the first pass (60 s), in each direction. All-cause mortality (ACM) served as the primary endpoint. RESULTS A total of 4,276 patients (median age 71 years; 60% male) were analyzed, and 1,007 ACM events were documented during a 5-year median follow-up. Processing time for automatic motion correction was < 12 s per patient. Myocardial creep in the superior to inferior (downward) direction was greater than the other directions (median, 4.2 mm vs. 1.3-1.7 mm). Annual mortality rates adjusted for age and sex were reduced with a larger downward creep, with a 4.2-fold ratio between the first (0 mm motion) and 10th decile (11 mm motion) (mortality, 7.9% vs. 1.9%/year). Downward creep was associated with lower ACM after full adjustment for clinical and imaging parameters (adjusted hazard ratio, 0.93; 95%CI, 0.91-0.95; p < 0.001). Adding downward creep to the standard PET-MPI imaging model significantly improved ACM prediction (area under the receiver operating characteristics curve, 0.790 vs. 0.775; p < 0.001), but other directions did not (p > 0.5). CONCLUSIONS Downward myocardial creep during regadenoson stress carries additional information for the prediction of ACM beyond conventional flow and perfusion PET-MPI. This novel imaging biomarker is quantified automatically and rapidly from stress dynamic PET-MPI.
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Affiliation(s)
- Keiichiro Kuronuma
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
- Department of Cardiology, Nihon University, Tokyo, Japan
| | - Robert J H Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Chih-Chun Wei
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Ananya Singh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Mark H Lemley
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Serge D Van Kriekinge
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Paul B Kavanagh
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Heidi Gransar
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Donghee Han
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Sean W Hayes
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Louise Thomson
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Damini Dey
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - John D Friedman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Daniel S Berman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
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Han D, Hyun MC, Miller RJH, Gransar H, Slomka PJ, Dey D, Hayes SW, Friedman JD, Thomson LEJ, Berman DS, Rozanski A. 10-year experience of utilizing a stress-first SPECT myocardial perfusion imaging. Int J Cardiol 2024; 401:131863. [PMID: 38365012 DOI: 10.1016/j.ijcard.2024.131863] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/24/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Despite its potential benefits, the utilization of stress-only protocol in clinical practice has been limited. We report utilizing stress-first single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). METHODS We assessed 12,472 patients who were referred for SPECT-MPI between 2013 and 2020. The temporal changes in frequency of stress-only imaging were assessed according to risk factors, mode of stress, prior coronary artery disease (CAD) history, left ventricular function, and symptom status. The clinical endpoint was all-cause mortality. RESULTS In our lab, stress/rest SPECT-MPI in place of rest/stress SPECT-MPI was first introduced in November 2011 and was performed more commonly than rest/stress imaging after 2013. Stress-only SPECT-MPI scanning has been performed in 30-34% of our SPECT-MPI studies since 2013 (i.e.. 31.7% in 2013 and 33.6% in 2020). During the study period, we routinely used two-position imaging (additional prone or upright imaging) to reduce attenuation and motion artifact and introduced SPECT/CT scanner in 2018. The rate of stress-only study remained consistent before and after implementing the SPECT/CT scanner. The frequency of stress-only imaging was 43% among patients without a history of prior CAD and 19% among those with a prior CAD history. Among patients undergoing treadmill exercise, the frequency of stress-only imaging was 48%, while 32% among patients undergoing pharmacologic stress test. In multivariate Cox analysis, there was no significant difference in mortality risk between stress-only and stress/rest protocols in patients with normal SPECT-MPI results (p = 0.271). CONCLUSION Implementation of a stress-first imaging protocol has consistently resulted in safe cancellation of 30% of rest SPECT-MPI studies.
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Affiliation(s)
- Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Mark C Hyun
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Piotr J Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Damini Dey
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Alan Rozanski
- The Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Natanzon SS, Han D, Kuronuma K, Gransar H, Miller RJH, Slomka PJ, Dey D, Hayes SW, Friedman JD, Thomson LEJ, Berman DS, Rozanski A. Self-reported exercise activity influences the relationship between coronary computed tomography angiographic finding and mortality. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00070-4. [PMID: 38589269 DOI: 10.1016/j.jcct.2024.03.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/04/2024] [Accepted: 03/22/2024] [Indexed: 04/10/2024]
Abstract
AIM Recent studies suggest that the application of exercise activity questionnaires, including the use of a single-item exercise question, can be additive to the prognostic efficacy of imaging findings. This study aims to evaluate the prognostic efficacy of exercise activity in patients undergoing coronary computed tomography angiography (CCTA). METHODS AND RESULTS We assessed 9772 patients who underwent CCTA at a single center between 2007 and 2020. Patients were divided into 4 groups of physical activity as no exercise (n = 1643, 17%), mild exercise (n = 3156, 32%), moderate exercise (n = 3542, 36%), and high exercise (n = 1431,15%), based on a single-item self-reported questionnaire. Coronary stenosis was categorized as no (0%), non-obstructive (1-49%), borderline (50-69%), and obstructive (≥70%). During a median follow-up of 4.64 (IQR 1.53-7.89) years, 490 (7.6%) died. There was a stepwise inverse relationship between exercise activity and mortality (p < 0.001). Compared with the high activity group, the no activity group had a 3-fold higher mortality risk (HR: 3.3, 95%CI (1.94-5.63), p < 0.001) after adjustment for age, clinical risk factors, symptoms, and statin use. For any level of CCTA stenosis, mortality rates were inversely associated with the degree of patients' exercise activity. The risk of all-cause mortality was similar among the patients with obstructive stenosis with high exercise versus those with no coronary stenosis but no exercise activity (p = 0.912). CONCLUSION Physical activity as assessed by a single-item self-reported questionnaire is a strong stepwise inverse predictor of mortality risk among patients undergoing CCTA.
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Affiliation(s)
- Sharon Shalom Natanzon
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Donghee Han
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Keiichiro Kuronuma
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alan Rozanski
- Division of Cardiac Sciences, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Rozanski A, Miller RJH, Han D, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Comparative predictors of mortality among patients referred for stress single-photon emission computed tomography versus positron emission tomography myocardial perfusion imaging. J Nucl Cardiol 2024; 32:101811. [PMID: 38244976 DOI: 10.1016/j.nuclcard.2024.101811] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
BACKGROUND There is currently little information regarding the usage and comparative predictors of mortality among patients referred for single-photon emission computed tomography (SPECT) versus positron emission tomography (PET) myocardial perfusion imaging (MPI) within multimodality imaging laboratories. METHODS We compared the clinical characteristics and mortality outcomes among 15,718 patients referred for SPECT-MPI and 6202 patients referred for PET-MPI between 2008 and 2017. RESULTS Approximately two-thirds of MPI studies were performed using SPECT-MPI. The PET-MPI group was substantially older and included more patients with known coronary artery disease (CAD), hypertension, diabetes, and myocardial ischemia. The annualized mortality rate was also higher in the PET-MPI group, and this difference persisted after propensity matching 3615 SPECT-MPI and 3615 PET-MPI patients to have similar clinical profiles. Among the SPECT-MPI patients, the most potent predictor of mortality was exercise ability and performance, including consideration of patients' mode of stress testing and exercise duration. Among the PET-MPI patients, myocardial flow reserve (MFR) was the most potent predictor of mortality. CONCLUSIONS In our real-world setting, PET-MPI was more commonly employed among older patients with more cardiac risk factors than SPECT-MPI patients. The most potent predictors of mortality in our SPECT and PET-MPI groups were variables exclusive to each test: exercise ability/capacity for SPECT-MPI patients and MFR for PET-MPI patients.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada
| | - Donghee Han
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- The Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Kuronuma K, Wei CC, Singh A, Lemley M, Hayes SW, Otaki Y, Hyun MC, Van Kriekinge SD, Kavanagh P, Huang C, Han D, Dey D, Berman DS, Slomka PJ. Automated Motion Correction for Myocardial Blood Flow Measurements and Diagnostic Performance of 82Rb PET Myocardial Perfusion Imaging. J Nucl Med 2024; 65:139-146. [PMID: 38050106 PMCID: PMC10755521 DOI: 10.2967/jnumed.123.266208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/17/2023] [Indexed: 12/06/2023] Open
Abstract
Motion correction (MC) affects myocardial blood flow (MBF) measurements in 82Rb PET myocardial perfusion imaging (MPI); however, frame-by-frame manual MC of dynamic frames is time-consuming. This study aims to develop an automated MC algorithm for time-activity curves used in compartmental modeling and compare the predictive value of MBF with and without automated MC for significant coronary artery disease (CAD). Methods: In total, 565 patients who underwent PET-MPI were considered. Patients without angiographic findings were split into training (n = 112) and validation (n = 112) groups. The automated MC algorithm used simplex iterative optimization of a count-based cost function and was developed using the training group. MBF measurements with automated MC were compared with those with manual MC in the validation group. In a separate cohort, 341 patients who underwent PET-MPI and invasive coronary angiography were enrolled in the angiographic group. The predictive performance in patients with significant CAD (≥70% stenosis) was compared between MBF measurements with and without automated MC. Results: In the validation group (n = 112), MBF measurements with automated and manual MC showed strong correlations (r = 0.98 for stress MBF and r = 0.99 for rest MBF). The automatic MC took less time than the manual MC (<12 s vs. 10 min per case). In the angiographic group (n = 341), MBF measurements with automated MC decreased significantly compared with those without (stress MBF, 2.16 vs. 2.26 mL/g/min; rest MBF, 1.12 vs. 1.14 mL/g/min; MFR, 2.02 vs. 2.10; all P < 0.05). The area under the curve (AUC) for the detection of significant CAD by stress MBF with automated MC was higher than that without (AUC, 95% CI, 0.76 [0.71-0.80] vs. 0.73 [0.68-0.78]; P < 0.05). The addition of stress MBF with automated MC to the model with ischemic total perfusion deficit showed higher diagnostic performance for detection of significant CAD (AUC, 95% CI, 0.82 [0.77-0.86] vs. 0.78 [0.74-0.83]; P = 0.022), but the addition of stress MBF without MC to the model with ischemic total perfusion deficit did not reach significance (AUC, 95% CI, 0.81 [0.76-0.85] vs. 0.78 [0.74-0.83]; P = 0.067). Conclusion: Automated MC on 82Rb PET-MPI can be performed rapidly with excellent agreement with experienced operators. Stress MBF with automated MC showed significantly higher diagnostic performance than without MC.
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Affiliation(s)
- Keiichiro Kuronuma
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
- Department of Cardiology, Nihon University, Tokyo, Japan
| | - Chih-Chun Wei
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Ananya Singh
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Mark Lemley
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Sean W Hayes
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Yuka Otaki
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Mark C Hyun
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Serge D Van Kriekinge
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Paul Kavanagh
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Cathleen Huang
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Donghee Han
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Damini Dey
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Daniel S Berman
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Piotr J Slomka
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
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Rozanski A, Han D, Miller RJH, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS. Is typical angina still prognostically important? The influence of "treatment bias" upon prognostic assessments. J Nucl Cardiol 2024; 31:101778. [PMID: 38237364 DOI: 10.1016/j.nuclcard.2023.101778] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
BACKGROUND Since typical angina has become less frequent, it is unclear if this symptom still has prognostic significance. METHODS We evaluated 38,383 patients undergoing stress/rest SPECT myocardial perfusion imaging followed for a median of 10.9 years. After dividing patients by clinical symptoms, we evaluated the magnitude of myocardial ischemia and subsequent mortality among medically treated versus revascularized subgroups following testing. RESULTS Patients with typical angina had more frequent and greater ischemia than other symptom groups, but not higher mortality. Among typical angina patients, those who underwent early revascularization had substantially greater ischemia than the medically treated subgroup, including a far higher proportion with severe ischemia (44.9% vs 4.3%, P < 0.001) and transient ischemic dilation of the LV (31.3% vs 4.7%, P < 0.001). Nevertheless, the revascularized typical angina subgroup had a lower adjusted mortality risk than the medically treated subgroup (HR = 0.72, 95% CI: 0.57-0.92, P = 0.009) CONCLUSIONS: Typical angina is associated with substantially more ischemia than other clinical symptoms. However, the high referral of patients with typical angina patients with ischemia to early revascularization resulted in this group having a lower rather than higher mortality risk versus other symptom groups. These findings illustrate the need to account for "treatment bias" among prognostic studies.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, New York, NY, USA.
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, CA, USA
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Louise Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, USA
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Rozanski A, Gransar H, Sakul S, Miller RJH, Han D, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Increasing frequency of dyspnea among patients referred for cardiac stress testing. J Nucl Cardiol 2023; 30:2303-2313. [PMID: 37861920 DOI: 10.1007/s12350-023-03375-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/09/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To assess the frequency, change in prevalence, and prognostic significance of dyspnea among contemporary patients referred for cardiac stress testing. PATIENTS AND METHODS We evaluated the prevalence of dyspnea and its relationship to all-cause mortality among 33,564 patients undergoing stress/rest SPECT-MPI between January 1, 2002 and December 31, 2017. Dyspnea was assessed as a single-item question. Patients were divided into three temporal groups. RESULTS The overall prevalence of dyspnea in our cohort was 30.2%. However, there was a stepwise increase in the temporal prevalence of dyspnea, which was present in 25.6% of patients studied between 2002 and 2006, 30.5% of patients studied between 2007 and 2011, and 38.7% of patients studied between 2012 and 2017. There was a temporal increase in the prevalence of dyspnea in each age, symptom, and risk factor subgroup. The adjusted hazard ratio for mortality was higher among patients with dyspnea vs those without dyspnea both among all patients, and within each chest pain subgroup. CONCLUSIONS Dyspnea has become increasingly prevalent among patients referred for cardiac stress testing and is now present among nearly two-fifths of contemporary cohorts referred for stress-rest SPECT-MPI. Prospective study is needed to standardize the assessment of dyspnea and evaluate the reasons for its increasing prevalence.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sakul Sakul
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Rozanski A, Han D, Miller RJH, Gransar H, Slomka P, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Comparison of coronary artery calcium scores among patients referred for cardiac imaging tests. Prog Cardiovasc Dis 2023; 81:24-32. [PMID: 37858662 DOI: 10.1016/j.pcad.2023.10.005] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND While coronary artery calcium (CAC) can now be evaluated by multiple imaging modalities, there is presently scant study regarding how CAC scores may vary among populations of varying clinical risk. METHODS We evaluated the distribution of CAC scores among three patient groups: 18,941 referred for CAC scanning, 5101 referred for diagnostic coronary CT angiography (CCTA), and 3307 referred for diagnostic positron emission tomography (PET) myocardial perfusion imaging (MPI). We assessed the relationship between CAC score and myocardial ischemia, obstructive coronary artery disease (CAD), and all-cause mortality across imaging modalities. RESULTS Within each age group, the frequency of CAC abnormalities were relatively similar across testing modalities, despite an annualized mortality rate which varied from 0.5%/year among CAC patients to 3.8%/year among PET-MPI patients (p < 0.001). Among CCTA and PET-MPI patients, a zero CAC score was common, occurring in ~70% of patients <50 years, ~40% of patients 50-59 years, and ~ 25% of patients 60-69 years. Among CCTA patients, zero CAC was associated with a normal coronary angiogram with high frequency, ranging from 92.2% among patients <50 years to 87.9% among patients ≥70 years. Among PET-MPI patients, zero CAC was associated with a very low frequency of inducible ischemia across all age groups, ranging from 1.5% among patients <50 years to 0.9% among patients ≥70 years. CONCLUSIONS In our study, relatively similar CAC scores were noted among patients varying markedly in mortality risk. Clinically, zero CAC scores predicted both a low likelihood of obstructive CAD and inducible myocardial ischemia in all age groups and were observed with high frequency across diagnostic testing modalities.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Robert J H Miller
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Piotr Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Rozanski A, Han D, Miller RJH, Gransar H, Slomka PJ, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Decline in typical angina among patients referred for cardiac stress testing. J Nucl Cardiol 2023; 30:1309-1320. [PMID: 37415006 DOI: 10.1007/s12350-023-03305-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To evaluate temporal trends in the prevalence of typical angina and its clinical correlates among patients referred for stress/rest SPECT myocardial perfusion imaging (MPI). PATIENTS AND METHODS We evaluated the prevalence of chest pain symptoms and their relationship to inducible myocardial ischemia among 61,717 patients undergoing stress/rest SPECT-MPI between January 2, 1991 and December 31, 2017. We also assessed the relationship between chest pain symptom and angiographic findings among 6,579 patients undergoing coronary CT angiography between 2011 and 2017. RESULTS The prevalence of typical angina among SPECT-MPI patients declined from 16.2% between 1991 and 1997 to 3.1% between 2011 and 2017, while the prevalence of dyspnea without any chest pain increased from 5.9 to 14.5% over the same period. The frequency of inducible myocardial ischemia declined over time within all symptom groups, but its frequency among current patients (2011-2017) with typical angina was approximately three-fold higher versus other symptom groups (28.4% versus 8.6%, p < 0.001). Overall, patients with typical angina had a higher prevalence of obstructive CAD on CCTA than those with other clinical symptoms, but 33.3% of typical angina patients had no coronary stenoses, 31.1% had 1-49% stenoses, and 35.4% had ≥ 50% stenoses. CONCLUSIONS The prevalence of typical angina has declined to a very low level among contemporary patients referred for noninvasive cardiac tests. The angiographic findings among current typical angina patients are now quite heterogeneous, with one-third of such patients having normal coronary angiograms. However, typical angina remains associated with a substantially higher frequency of inducible myocardial ischemia compared to patients with other cardiac symptoms.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr J Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Malhotra P, Gheyath B, Han D, Dey D, Hayes SW, Friedman JD, Thomson L, Kwan A, Berman DS. ACCURACY OF CORONARY CT ANGIOGRAPHY IN PATIENTS WITH CORONARY STENTS: COMPARISON WITH QUANTITATIVE CORONARY ANGIOGRAPHY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01949-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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Kuronuma K, Miller RJH, Wei CC, Singh A, Lemley M, Van Kriekinge SD, Kavanagh P, Gransar H, Han D, Hayes SW, Thomson L, Dey D, Friedman JD, Berman DS, Slomka P. DOWNWARD MYOCARDIAL CREEP AUTOMATICALLY QUANTIFIED DURING STRESS POSITRON EMISSION TOMOGRAPHY MYOCARDIAL PERFUSION IMAGING IS INVERSELY ASSOCIATED WITH MORTALITY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01948-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Lin B, Han D, Gransar H, Rozanski A, Miller R, Dey D, Hayes SW, Friedman JD, Thomson L, Berman DS. CORONARY ARTERY CALCIUM SCORE IS MORE PREDICTIVE FOR RISK OF MORTALITY THAN SEGMENT INVOLVEMENT SCORE BY CORONARY ARTERY DISEASE REPORTING AND DATA SYSTEM 2.0 CLASSIFICATION CATEGORIES FOR PLAQUE BURDEN. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01809-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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13
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Malhotra P, Han D, Singh A, Miller RJH, Gransar H, Hayes SW, Friedman JD, Thomson L, Rozanski A, Slomka P, Berman DS. DIFFERENCES IN MYOCARDIAL FLOW RESERVE AND PROGNOSIS BETWEEN PATIENTS WITH AND WITHOUT DIABETES. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01944-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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Miller RJH, Rozanski A, Slomka PJ, Han D, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Development and validation of ischemia risk scores. J Nucl Cardiol 2023; 30:324-334. [PMID: 35484468 DOI: 10.1007/s12350-022-02976-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The likelihood of ischemia on myocardial perfusion imaging is central to physician decisions regarding test selection, but dedicated risk scores are lacking. We derived and validated two novel ischemia risk scores to support physician decision making. METHODS Risk scores were derived using 15,186 patients and validated with 2,995 patients from a different center. Logistic regression was used to assess associations with ischemia to derive point-based and calculated ischemia scores. Predictive performance for ischemia was assessed using area under the receiver operating characteristic curve (AUC) and compared with the CAD consortium basic and clinical models. RESULTS During derivation, the calculated ischemia risk score (0.801) had higher AUC compared to the point-based score (0.786, p < 0.001). During validation, the calculated ischemia score (0.716, 95% CI 0.684- 0.748) had higher AUC compared to the point-based ischemia score (0.699, 95% CI 0.666- 0.732, p = 0.016) and the clinical CAD model (AUC 0.667, 95% CI 0.633- 0.701, p = 0.002). Calibration for both ischemia scores was good in both populations (Brier score < 0.100). CONCLUSIONS We developed two novel risk scores for predicting probability of ischemia on MPI which demonstrated high accuracy during model derivation and in external testing. These scores could support physician decisions regarding diagnostic testing strategies.
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Affiliation(s)
- Robert J H Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Alan Rozanski
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Cardiology and Department of Medicine, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Cardiac Sciences, Mount Sinai Morningside Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Piotr J Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Donghee Han
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Reynolds HR, Diaz A, Cyr DD, Shaw LJ, Mancini GBJ, Leipsic J, Budoff MJ, Min JK, Hague CJ, Berman DS, Chaitman BR, Picard MH, Hayes SW, Scherrer-Crosbie M, Kwong RY, Lopes RD, Senior R, Dwivedi SK, Miller TD, Chow BJW, de Silva R, Stone GW, Boden WE, Bangalore S, O'Brien SM, Hochman JS, Maron DJ. Ischemia With Nonobstructive Coronary Arteries: Insights From the ISCHEMIA Trial. JACC Cardiovasc Imaging 2023; 16:63-74. [PMID: 36115814 PMCID: PMC9878463 DOI: 10.1016/j.jcmg.2022.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/10/2022] [Accepted: 06/23/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Ischemia with nonobstructive coronary arteries (INOCA) is common clinically, particularly among women, but its prevalence among patients with at least moderate ischemia and the relationship between ischemia severity and non-obstructive atherosclerosis severity are unknown. OBJECTIVES The authors investigated predictors of INOCA in enrolled, nonrandomized participants in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), sex differences, and the relationship between ischemia and atherosclerosis in patients with INOCA. METHODS Core laboratories independently reviewed screening noninvasive stress test results (nuclear imaging, echocardiography, magnetic resonance imaging or nonimaging exercise tolerance testing), and coronary computed tomography angiography (CCTA), blinded to results of the screening test. INOCA was defined as all stenoses <50% on CCTA in a patient with moderate or severe ischemia on stress testing. INOCA patients, who were excluded from randomization, were compared with randomized participants with ≥50% stenosis in ≥1 vessel and moderate or severe ischemia. RESULTS Among 3,612 participants with core laboratory-confirmed moderate or severe ischemia and interpretable CCTA, 476 (13%) had INOCA. Patients with INOCA were younger, were predominantly female, and had fewer atherosclerosis risk factors. For each stress testing modality, the extent of ischemia tended to be less among patients with INOCA, particularly with nuclear imaging. There was no significant relationship between severity of ischemia and extent or severity of nonobstructive atherosclerosis on CCTA. On multivariable analysis, female sex was independently associated with INOCA (odds ratio: 4.2 [95% CI: 3.4-5.2]). CONCLUSIONS Among participants enrolled in ISCHEMIA with core laboratory-confirmed moderate or severe ischemia, the prevalence of INOCA was 13%. Severity of ischemia was not associated with severity of nonobstructive atherosclerosis. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Harmony R Reynolds
- New York University Grossman School of Medicine, New York, New York, USA.
| | - Ariel Diaz
- CIUSSS-MCQ, University of Montreal, Campus Mauricie, Trois-Rivieres, Quebec, Canada
| | - Derek D Cyr
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Leslee J Shaw
- New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA
| | - G B John Mancini
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Cameron J Hague
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Bernard R Chaitman
- St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis, Missouri, USA
| | - Michael H Picard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sean W Hayes
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | | | | | | | | | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, New York, USA
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Judith S Hochman
- New York University Grossman School of Medicine, New York, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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16
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Kuronuma K, Han D, Miller RJH, Rozanski A, Gransar H, Dey D, Hayes SW, Friedman JD, Thomson L, Slomka PJ, Berman DS. Long-term Survival Benefit From Revascularization Compared With Medical Therapy in Patients With or Without Diabetes Undergoing Myocardial Perfusion Single Photon Emission Computed Tomography. Diabetes Care 2022; 45:3016-3023. [PMID: 36001757 DOI: 10.2337/dc22-0454] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Received: 03/04/2022] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the long-term association of survival benefit from early revascularization with the magnitude of ischemia in patients with diabetes compared with those without diabetes using a large observational cohort of patients undergoing single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). RESEARCH DESIGN AND METHODS Of 41,982 patients who underwent stress and rest SPECT-MPI from 1998 to 2017, 8,328 (19.8%) had diabetes. A propensity score was used to match 8,046 patients with diabetes to 8,046 patients without diabetes. Early revascularization was defined as occurring within 90 days after SPECT-MPI. The percentage of myocardial ischemia was assessed from the magnitude of reversible myocardial perfusion defect on SPECT-MPI. RESULTS Over a median 10.3-year follow-up, the annualized mortality rate was higher for the patients with diabetes compared with those without diabetes (4.7 vs. 3.6%; P < 0.001). There were significant interactions between early revascularization and percent myocardial ischemia in patients with and without diabetes (all interaction P values <0.05). After adjusting for confounding variables, survival benefit from early revascularization was observed in patients with diabetes above a threshold of >8.6% ischemia and in patients without diabetes above a threshold of >12.1%. Patients with diabetes receiving insulin had a higher mortality rate (6.2 vs. 4.1%; P < 0.001), but there was no interaction between revascularization and insulin use (interaction P value = 0.405). CONCLUSIONS Patients with diabetes, especially those on insulin treatment, had higher mortality rate compared with patients without diabetes. Early revascularization was associated with a mortality benefit at a lower ischemic threshold in patients with diabetes compared with those without diabetes.
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Affiliation(s)
- Keiichiro Kuronuma
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Cardiology, Nihon University, Tokyo, Japan
| | - Donghee Han
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, New York, NY
| | - Heidi Gransar
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Damini Dey
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sean W Hayes
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John D Friedman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise Thomson
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Piotr J Slomka
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S Berman
- Department of Imaging, Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
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Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS. Mortality risk among patients undergoing exercise versus pharmacologic myocardial perfusion imaging: A propensity-based comparison. J Nucl Cardiol 2022; 29:840-852. [PMID: 33047282 DOI: 10.1007/s12350-020-02294-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/22/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND The increased risk associated with pharmacologic versus exercise testing is obscured by the higher prevalence of clinical risk factors among pharmacologic patients. Thus, we assessed comparative mortality in a large risk factor-matched group of exercise versus pharmacologic patients undergoing stress/rest SPECT myocardial perfusion imaging (MPI). METHODS 39,179 patients undergoing stress/rest SPECT-MPI were followed for 13.3 ± 5.0 years for all-cause mortality (ACM). We applied propensity-matching to create pharmacologic and exercise groups with similar risk profiles. RESULTS In comparison to exercise patients, pharmacologic patients had an increased risk-adjusted hazard ratio for ACM for each level of ischemia: increased by 3.8-fold (95%CI 3.5-4.1) among nonischemic patients, 2.5-fold (95%CI 2.0-3.2) among mildly ischemic patients, and 2.6-fold (95%CI 2.1-3.3) among moderate/severe ischemic patients. Similar findings were observed among a propensity-matched cohort of 10,113 exercise and 10,113 pharmacologic patients as well as in an additional cohort that also excluded patients with noncardiac co-morbidities. CONCLUSIONS Patients requiring pharmacologic stress testing manifest substantially heightened clinical risk at each level of myocardial ischemia and even when myocardial ischemia is absent. These findings suggest the need to study the pathophysiological drivers of increased risk in association with pharmacologic testing and to convey this risk in clinical reports.
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Affiliation(s)
- Alan Rozanski
- The Department of Cardiology, Mount Sinai Morningside Hospital and Mount Sinai Heart, 1111 Amsterdam Avenue, New York, 10025, USA.
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Sean W Hayes
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - John D Friedman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Louise Thomson
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Daniel S Berman
- Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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Tummala R, Han D, Razipour A, Lin A, Hayes SW, Thomson L, Friedman JD, Slomka P, Rozanski A, Berman DS, Dey D. IMPACT OF GENDER ON THE ASSOCIATIONS OF EPICARDIAL ADIPOSE TISSUE, CORONARY ARTERY CALCIUM, AND LIVER FIBROSIS IN PREDICTION OF MACE: SUBSTUDY OF THE EISNER TRIAL. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02228-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Asif A, Berman DS, Gransar H, Friedman JD, Hayes SW, Thomas LE, Merz CNB, Tamarappoo B. SEX DIFFERENCES IN PROGNOSTIC SIGNIFICANCE OF PLAQUE BURDEN AND DISTRIBUTION MEASURED BY CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY (CCTA) IN YOUNGER PATIENTS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02192-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Han D, Malhotra P, Miller RJH, Otaki Y, Gransar H, Hayes SW, Thomson L, Friedman JD, Rozanski A, Slomka P, Berman DS. RELATIONSHIP BETWEEN CORONARY ARTERY CALCIUM AND STRESS-INDUCED PERFUSION ABNORMALITY IN PATIENTS UNDERGOING RB-82 PET MPI. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02306-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Lavie CJ, Berman DS. Synergistic Assessment of Mortality Risk According to Body Mass Index and Exercise Ability and Capacity in Patients Referred for Radionuclide Stress Testing. Mayo Clin Proc 2021; 96:3001-3011. [PMID: 34311969 DOI: 10.1016/j.mayocp.2021.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/11/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the interrelationship between body mass index (BMI), mode of stress testing (exercise or pharmacological), exercise capacity, and all-cause mortality in patients referred for stress-rest single photon emission computed tomography myocardial perfusion imaging. PATIENTS AND METHODS We evaluated all-cause mortality in 21,638 patients undergoing stress-rest single photon emission computed tomography myocardial perfusion imaging between January 2, 1991, and December 31, 2012. Patients were divided into exercise and pharmacologically tested groups and 9 BMI categories. The median follow-up was 12.8 years (range, 5.0-26.8 years). RESULTS In exercise patients, mortality was increased with both low and high BMI vs patients with a normal referent BMI of 22.5 to 24.9 kg/m2. In pharmacologically tested patients, only low BMI, but not high BMI, was associated with increased mortality vs normal BMI. When exercise and pharmacologically tested groups were compared directly, pharmacologically tested patients manifested a marked increase in mortality risk vs exercise patients within each BMI category, ranging from an approximately 4-fold increase in mortality in those with normal or high BMI to a 12.3-fold increase in those with low BMI values. Similar findings were observed in a cohort of 4804 exercise and 4804 pharmacologically tested patients matched to have similar age and coronary artery disease risk factor profiles. In exercise patients, further risk stratification was achieved when considering both BMI and metabolic equivalent tasks of achieved exercise. CONCLUSION The combined assessment of BMI and exercise ability and capacity provides synergistic and marked risk stratification of future mortality risk in patients referred for radionuclide stress testing, providing considerable insights into the "obesity paradox" that is observed in populations referred for stress testing.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Heidi Gransar
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sean W Hayes
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John D Friedman
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise E J Thomson
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA
| | - Daniel S Berman
- Department of Imaging and Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Tzolos E, Han D, Klein E, Friedman JD, Hayes SW, Thomson LEJ, Slomka P, Dey D, Gransar H, Berman DS. Detection of small coronary calcifications in patients with Agatston coronary artery calcium score of zero. J Cardiovasc Comput Tomogr 2021; 16:150-154. [PMID: 34740559 DOI: 10.1016/j.jcct.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/11/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND A coronary artery calcium score (CACS) of 0 is associated with a very low risk of cardiac event. However, the Agatston CACS may fail to detect very small or less dense calcifications. We investigated if an alteration of the Agatston criteria would affect the ability to detect such plaques. METHODS We evaluated 322 patients, 161 who had a baseline scan with CACS = 0 and a follow-up scan with CACS>0 and 161 with two serial CACS = 0 scans (control group), to identify subtle calcification not detected in the baseline scan because it was not meeting the Agatston size and HU thresholds (≥1 mm2 and ≥130HU). Size threshold was set to <1 mm2 and the HU threshold modified in a stepwise manner to 120, 110, 100 and 90. New lesions were classified as true positive or false positive(noise) using the follow-up scan. RESULTS We identified 69 visually suspected subtle calcified lesions in 65/322 (20.2%) patients with CAC = 0 by the Agatston criteria. When size threshold was set as <1 mm2 and HU ≥ 130, 36 lesions scored CACS>0, 34 (94.4%) true positive and 2 (5.6%) false positive. When decrease in HU (120HU, 110HU, 100HU, and 90HU) threshold was added to the reduced size threshold, the number of lesions scoring>0 increased (46, 55, 59, and 69, respectively) at a cost of increased false positive rate (8.7%, 20%, 22%, and 30.4% respectively). Eliminating size or both size and HU threshold to ≥120HU correctly reclassified 9.6% and 12.1% of patients respectively. CONCLUSION Eliminating size and reducing HU thresholds to ≥120HU improved the detection of subtle calcification when compared to the Agatston CACS method.
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Affiliation(s)
- Evangelos Tzolos
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA; BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Donghee Han
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eyal Klein
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean W Hayes
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Piotr Slomka
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heidi Gransar
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Feasibility of Using an Ultrashort Lifestyle Questionnaire to Predict Future Mortality Risk among Patients with Suspected Heart Disease. Am J Cardiol 2021; 153:36-42. [PMID: 34215356 DOI: 10.1016/j.amjcard.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
Adverse health behaviors are potent drivers of chronic disease and premature mortality. This has led to the development of various lifestyle scores to predict clinical risk, but their complexity makes them impractical for use in clinical settings. Thus, there is a need to develop a brief lifestyle score that can assess factors such as exercise and diet within the constraints of routine medical practice. Accordingly, we assessed 19,081 patients undergoing coronary artery calcium (CAC) scanning between September 1, 1998 and December 30, 2016. Each patient completed a questionnaire that included a two-item lifestyle scale regarding patients' frequency of exercise and adherence to a low saturated fat diet. Patients' responses were used to generate a lifestyle score which ranged from very low risk to high risk. Patients were followed for a median of 11.0 years for all-cause mortality. A stepwise relationship was noted between worse lifestyle scores and increased frequency of hypertension, diabetes, smoking, obesity, waist/hip ratio, and resting heart rate and blood pressure. Among patients with zero CAC scores, mortality risk was low regardless of lifestyle score, but as CAC abnormality increased, a stepwise relationship emerged between worse lifestyle scores and mortality. The lifestyle score was more predictive of mortality than conventional CAD risk factors according to multivariable Chi-square analysis. Thus, our results establish the practicality of an ultrashort lifestyle questionnaire that could be employed in nearly all clinical settings. Within our study, our two-item lifestyle scale showed a stepwise relationship to known CAD risk factors and predicted future mortality.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Heidi Gransar
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sean W Hayes
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John D Friedman
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise E J Thomson
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S Berman
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Otaki Y, Han D, Klein E, Gransar H, Park RH, Tamarappoo B, Hayes SW, Friedman JD, Thomson LEJ, Slomka PJ, Dey D, Cheng V, Miller RJ, Berman DS. Value of semiquantitative assessment of high-risk plaque features on coronary CT angiography over stenosis in selection of studies for FFRct. J Cardiovasc Comput Tomogr 2021; 16:27-33. [PMID: 34246594 DOI: 10.1016/j.jcct.2021.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/07/2021] [Accepted: 06/14/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The degree of stenosis on coronary CT angiography (CCTA) guides referral for CT-derived flow reserve (FFRct). We sought to assess whether semiquantitative assessment of high-risk plaque (HRP) features on CCTA improves selection of studies for FFRct over stenosis assessment alone. METHODS Per-vessel FFRct was computed in 1,395 vessels of 836 patients undergoing CCTA with 25-99% maximal stenosis. By consensus analysis, stenosis severity was graded as 25-49%, 50-69%, 70-89%, and 90-99%. HRPs including low attenuation plaque (LAP), positive remodeling (PR), and spotty calcification (SC) were assessed in lesions with maximal stenosis. Lesion FFRct was measured distal to the lesion with maximal stenosis, and FFRct<0.80 was defined as abnormal. Association of HRP and abnormal lesion FFRct was evaluated by univariable and multivariable logistic regression models. RESULTS The frequency of abnormal lesion FFRct increased with increase of stenosis severity across each stenosis category (25-49%:6%; 50-69%:30%; 70-89%:54%; 90-99%:91%, p < 0.001). Univariable analysis demonstrated that stenosis severity, LAP, and PR were predictive of abnormal lesion FFRct, while SC was not. In multivariable analyses considering stenosis severity, presence of PR, LAP, and PR and/or LAP were independently associated with abnormal FFRct: Odds ratio 1.58, 1.68, and 1.53, respectively (p < 0.02 for all). The presence of PR and/or LAP increased the frequency of abnormal FFRct with mild stenosis (p < 0.05) with a similar trend with 70-89% stenosis. The combination of 2 HRP (LAP and PR) identified more lesions with FFR < 0.80 than only 1 HRP. CONCLUSIONS Semiquantitative visual assessment of high-risk plaque features may improve the selection of studies for FFRct.
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Affiliation(s)
- Yuka Otaki
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Donghee Han
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Eyal Klein
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Heidi Gransar
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Rebekah H Park
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Balaji Tamarappoo
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Sean W Hayes
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - John D Friedman
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Louise E J Thomson
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Piotr J Slomka
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Damini Dey
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Victor Cheng
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Robert Jh Miller
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel S Berman
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, The Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
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Mehta PK, Thomson LEJ, Slomka PJ, Hayes SW, Friedman JD, Swift A, Quesada O, Wei J, Shaw LJ, Nelson MD, Li L, Hermel D, Hermel MH, Irwin MR, Krantz DS, Travin MI, Pepine CJ, Berman DS, Bairey Merz CN. Cardiac Sympathetic Activity by 123I-Meta-Iodobenzylguanidine Imaging in Women With Coronary Microvascular Dysfunction: A Pilot Study. JACC Cardiovasc Imaging 2021; 14:1873-1875. [PMID: 34147436 DOI: 10.1016/j.jcmg.2021.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
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26
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Rozanski A, Arnson Y, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Relation of Intake of Saturated Fat to Atherosclerotic Risk Factors, Health Behaviors, Coronary Atherosclerosis, and All-Cause Mortality Among Patients Who Underwent Coronary Artery Calcium Scanning. Am J Cardiol 2021; 138:40-45. [PMID: 33058807 DOI: 10.1016/j.amjcard.2020.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/20/2023]
Abstract
Although very brief questionnaires are commonly used to assess physical activity, an analogous approach for assessing diet quality within clinical practice has not been developed. Thus, we undertook an exploratory study to evaluate the association between a single-item questionnaire regarding dietary quality and patient risk profiles, lifestyle habits, lipid values, coronary artery calcium (CAC) scores and mortality. We assessed 15,368 patients who underwent CAC scanning, followed for a median of 12.1 years for all-cause mortality. Diet quality was assessed according to a single-item question regarding self-reported adherence to a low saturated fat diet (0 = never, 10 = always), with patients categorized into 4 dietary groups based on their response, ranging from low to very high saturated fat intake. We observed a significant stepwise association between reported saturated fat intake and smoking, exercise activity, obesity, and serum cholesterol, low density lipoprotein, and triglyceride values. Following adjustment for age and risk factors, patients reporting very high saturated fat intake had an elevated hazard ratio for mortality versus low saturated fat intake: 1.22 (95% confidence interval 1.04 to 1.44). The hazard ratio was no longer significant after further adjustment for exercise activity. Upon division of patients according to baseline CAC, a stepwise relationship was noted between increasing saturated fat intake and mortality among patients with CAC scores ≥400 (p = 0.002). Thus, within our cohort, just a single-item exploratory questionnaire regarding very high saturated fat intake revealed stepwise associations with health behaviors and cardiac risk factors, suggesting the basis for further development of a practical dietary questionnaire for clinical purposes.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, New York; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | | | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Rozanski A, Gransar H, Miller RJH, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Association between coronary atherosclerotic burden and all-cause mortality among patients undergoing exercise versus pharmacologic stress-rest SPECT myocardial perfusion imaging. Atherosclerosis 2020; 310:45-53. [PMID: 32890806 DOI: 10.1016/j.atherosclerosis.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/26/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIMS Patients with suspected coronary artery disease who undergo stress SPECT myocardial perfusion imaging (MPI) and require pharmacologic stress are at substantially increased mortality risk compared to those who can exercise. However, the mechanisms underlying this increased risk are not well delineated. To test whether increased atherosclerotic burden accounts for this increased risk, we assessed the association between coronary artery calcium (CAC) scores and mortality risk among patients undergoing exercise versus pharmacologic SPECT MPI. METHODS We assessed all-cause mortality in 2,151 patients, followed for 12.2 ± 3.4 years, after undergoing stress-rest SPECT-MPI and CAC scanning within 3 months of each other. Patients were divided according to their mode of stress testing (exercise or pharmacologic). We further employed propensity analysis to create a subgroup of exercise and pharmacologic subgroups with comparable age, symptoms, and coronary risk factors. RESULTS Despite greater age and worse clinical profiles, pharmacologic and exercise patients had similar CAC scores. However, the hazard ratio (95% CI) for mortality was substantially greater among pharmacologic patients: 2.39 (1.83-3.10). For each level of CAC abnormality, pharmacologic patients had >2-fold increased risk adjusted hazard ratio for all-mortality risk (p < 0.05 for each CAC level). Among propensity-matched exercise versus pharmacologic patients, the same findings were observed. CONCLUSIONS Among patients referred for stress-rest SPECT-MPI and CAC scoring, pharmacologic patients have substantially increased mortality risk compared to exercise patients, despite having comparable levels of coronary atherosclerosis.
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, USA; Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Rozanski A, Arnson Y, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Dey D, Berman DS. Associations Among Self-reported Physical Activity, Coronary Artery Calcium Scores, and Mortality Risk in Older Adults. Mayo Clin Proc Innov Qual Outcomes 2020; 4:229-237. [PMID: 32542214 PMCID: PMC7283959 DOI: 10.1016/j.mayocpiqo.2020.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective To assess whether self-reported physical activity during daily life reduces the mortality risk associated with atherosclerotic burden, as measured by coronary artery calcium (CAC) scanning. Methods We assessed 2318 patients aged 65 to 84 years who underwent CAC scanning from August 31, 1998, through November 16, 2016, and had daily life physical activity assessed by a single-item question that was used to divide patients by low, moderate, and high physical activity levels. Patients were followed for a mean ± SD of 10.6±4.9 years for the occurrence of all-cause mortality. Results The results indicated a graded relationship between the magnitude of CAC abnormality and mortality and an inverse relationship between physical activity and mortality. Of patients with low CAC scores (0-99), those with low, moderate, and high physical activity levels had similarly low mortality rates. Of patients with high CAC scores (≥400), however, there was a stepwise increase in mortality with decreasing physical activity. Patients with CAC scores of 400 or greater but reporting high physical activity had a mortality rate that was similar vs that observed in patients with CAC scores of only 0 to 99 and low physical activity (19.9 vs 16.3 per 1000 person-years; P=.60). Conclusion Combining CAC score with self-reported physical activity level provides a synergistic means for predicting clinical risk in older patients, with high physical activity level substantially attenuating the mortality risk associated with elevated CAC scores. Moreover, the useful prognostic information afforded by just a single-item physical activity questionnaire supports current initiatives to make such assessments into a "fifth vital sign."
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Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai St Luke's Hospital, Mount Sinai Heart, and Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Heidi Gransar
- Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sean W Hayes
- Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John D Friedman
- Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Louise E J Thomson
- Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Damini Dey
- Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S Berman
- Department of Imaging, Department of Medicine, and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Aguilar J, Miller R, Tamarappoo B, Hayes SW, Friedman J, Slomka P, Thomson L, Patel J, Kobashigawa JA, Berman DS. LIMITED PROGNOSTIC ABILITY OF SPECT IN THE HEART TRANSPLANT POPULATION: ANALYSIS FROM A SINGLE LARGE-VOLUME CENTER. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32270-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Miller RJH, Pope A, Kransdorf EP, Hamilton MA, Patel J, Hayes SW, Friedman J, Thomson L, Tamarappoo B, Berman DS, Slomka P. QUANTITATIVE ASSESSMENT OF MYOCARDIAL HYPERMETABOLISM AND PERFUSION FOR DIAGNOSIS OF CARDIAC SARCOIDOSIS. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32275-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tamarappoo B, Otaki Y, Manabe O, Hyun M, Cantu S, Arnson Y, Gransar H, Hayes SW, Friedman JD, Thomson L, Slomka P, Dey D, Vescio R, Patel J, Berman DS. Simultaneous Tc-99m PYP/Tl-201 dual-isotope SPECT myocardial imaging in patients with suspected cardiac amyloidosis. J Nucl Cardiol 2020; 27:28-37. [PMID: 31172386 DOI: 10.1007/s12350-019-01753-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/28/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Assessment of myocardial uptake of Tc-99m-pyrophosphate (Tc-99m PYP) is pivotal in distinguishing transthyretin-associated cardiac amyloidosis (ATTR) from light chain amyloid (AL). It is often difficult to differentiate myocardial uptake from blood pool radioactivity with planar imaging or SPECT. We studied whether simultaneous dual-isotope Tc-99m PYP/Tl-201 SPECT improves assessment of Tc-99m PYP uptake compared to single-isotope SPECT. METHODS Simultaneous Tc-99m PYP/Tl-201 dual-isotope SPECT was acquired in 112 patients studied for possible cardiac amyloidosis. Visual interpretation was performed by two observers on single-isotope followed by dual-isotope SPECT. Heart-to-contralateral lung ratio (H/CL) of myocardial counts quantified by single-isotope and dual-isotope SPECT was compared between ATTR, AL, and no amyloidosis groups. RESULTS In 112 patients (39 ATTR and 26 AL patients, and 47 no amyloidosis), a lower proportion of no amyloidosis and AL patients were classified visually as equivocal with dual-isotope SPECT compared to single-isotope SPECT (2% vs 19%, P = 0.02 and 8% vs 35%, P = 0.04, respectively). H/CL measurements with single-isotope and dual-isotope were lower in AL and no amyloidosis patients vs ATTR patients (P < 0.05). Interobserver agreement of visual assessment was improved with dual-isotope SPECT (P = 0.03). AUCs for detection of ATTR by visual assessment and H/CL quantification were higher with dual-isotope (0.94 and 0.95, respectively) compared to single-isotope SPECT (0.84, P = 0.001 and 0.92, P = 0.02). CONCLUSION Tc-99m PYP/Tl-201 SPECT improves visual differentiation of ATTR and AL amyloidosis compared to single-isotope SPECT. Visual assessment and H/CL quantitation with dual-isotope SPECT provide similar discrimination between patients with ATTR and AL amyloidosis.
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Affiliation(s)
- Balaji Tamarappoo
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Yuka Otaki
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Osamu Manabe
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Mark Hyun
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Stephanie Cantu
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Yoav Arnson
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Heidi Gransar
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Sean W Hayes
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - John D Friedman
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Louise Thomson
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Piotr Slomka
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Damini Dey
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Robert Vescio
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Jignesh Patel
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, and the Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA.
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Wang F, Rozanski A, Dey D, Arnson Y, Gransar H, Friedman J, Hayes SW, Thomson LEJ, Tamarappoo B, Shaw LJ, Min JK, Rumberger JA, Budoff MJ, Miedema MD, Blaha MJ, Berman DS. Age- and gender-adjusted percentiles for number of calcified plaques in coronary artery calcium scanning. J Cardiovasc Comput Tomogr 2019; 13:319-324. [PMID: 30598344 DOI: 10.1016/j.jcct.2018.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Received: 08/12/2018] [Revised: 11/08/2018] [Accepted: 12/16/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Age- and gender-adjusted percentiles of coronary artery calcium (CAC) score are commonly reported to compare a patient's coronary atherosclerosis burden to that of others of the same age and gender. The number of calcified plaques (numCP) detected on CAC scanning, a measure of plaque diffusivity, is associated with increased cardiovascular risk and, in the intermediate CAC range, adds to the CAC score in predicting mortality. This study aims to develop adjusted percentiles for numCP to provide a better context for understanding CAC scan findings. METHODS AND RESULTS Using nonparametric modeling techniques, the distribution of numCP was analyzed in 70,320 consecutive, asymptomatic patients without prior clinically-diagnosed cardiovascular disease who were part of the Coronary Artery Calcium Consortium and supplemented by additional patients referred for clinical CAC scanning in a single center between 1998 and 2016. Nomograms for age-adjusted numCP percentiles for each gender were generated using quantile regression. The prevalence and average number of calcified coronary plaque were found to be higher in men than women. Distribution of numCP in women was found to closely mirror that of men approximately a decade younger. NumCP increased consistently across age groups in both men and women for each quantile category. CONCLUSIONS A nomogram for age and gender-adjusted percentiles for the numCP on CAC scans has been developed in a large population of asymptomatic patients studied across multiple centers. This numCP nomogram may provide an additional tool for refining physician recommendations regarding treatment and expressing to patients how their CAC findings relate to others of similar age and gender. The numCP percentiles may also provide a meaningful way to evaluate and report the rate of progression of CAC on serial studies.
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Affiliation(s)
- Frances Wang
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Alan Rozanski
- Division of Cardiology, Mt Sinai St. Luke's Hospital, Mount Sinai Heart and the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Damini Dey
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Yoav Arnson
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Heidi Gransar
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - John Friedman
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Sean W Hayes
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Louise E J Thomson
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Balaji Tamarappoo
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Leslee J Shaw
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine, New York, USA
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine, New York, USA
| | | | - Matthew J Budoff
- Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | - Michael J Blaha
- Prevention of Heart Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Ciccarone Center, Baltimore, MD, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
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Arnson Y, Rozanski A, Gransar H, Friedman JD, Hayes SW, Thomson LE, Tamarappoo B, Slomka P, Wang F, Germano G, Dey D, Berman DS. Comparison of the Coronary Artery Calcium Score and Number of Calcified Coronary Plaques for Predicting Patient Mortality Risk. Am J Cardiol 2017; 120:2154-2159. [PMID: 29096884 DOI: 10.1016/j.amjcard.2017.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 10/18/2022]
Abstract
Multiple coronary artery calcium (CAC) parameters have recently been proposed to improve risk prediction in patients with intermediate clinical risk based on CAC scoring, but outcome data that assess these variables are relatively sparse. We analyzed data from 11,633 consecutive asymptomatic patients undergoing CAC scanning that were followed for 8.8 ± 3.5 years for all-cause mortality (ACM). The patients who had coronary artery calcification were grouped by the number of calcified coronary plaques: 0, 1 to 5, 6 to 20, and >20 plaques. We examined the independent prognostic value of plaque number and its synergistic prognostic value when added to the CAC score. We observed a stepwise increase in ACM with increasing plaque number. In patients with a CAC score of 1 to 99, 6 plaques or more were associated with increased mortality. In patients with CAC scores of 100 to 399, there was a stepwise increase in ACM with increasing plaque number. For CAC >400, the risk of ACM was high regardless of plaque number. After risk adjustment, the number of plaques was a significant predictor of risk for ACM in the patients with an intermediate CAC score. In these patients, additional consideration of plaque number improved net reclassification improvement for predicting ACM by 29%. In conclusion, the number of calcified plaques adds to risk stratification beyond the CAC score in patients with intermediate CAC scores.
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Arnson Y, Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Impact of Exercise on the Relationship Between CAC Scores and All-Cause Mortality. JACC Cardiovasc Imaging 2017; 10:1461-1468. [PMID: 28528154 DOI: 10.1016/j.jcmg.2016.12.030] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 11/22/2016] [Accepted: 12/06/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study aims to assess the correlations among coronary artery calcium (CAC), self-reported exercise, and mortality in asymptomatic patients. BACKGROUND The interaction between reported exercise habits and CAC scores for predicting clinical risk is not yet well known. METHODS We followed 10,690 asymptomatic patients who underwent CAC scanning. Patients were divided into 4 groups based on a single-item self-reported exercise. Mean follow-up was 8.9 ± 3.5 years for the occurrence of all-cause mortality (ACM). RESULTS Annualized ACM progressively increased with increasing CAC score (p < 0.001) and decreasing exercise (p < 0.001). Among patients with CAC scores of 0, ACM was low regardless of the amount of exercise. Among patients with CAC scores from 1 to 399, there was a stepwise increase in ACM for each reported decrement in exercise, and this difference was markedly more pronounced among patients with CAC scores ≥400. Compared with highly active patients with a CAC score of 0, highly sedentary patients with CAC scores ≥400 had a 3.1-fold increase (95% confidence interval: 1.35 to 7.11) in adjusted ACM risk. Our single-item physical activity questionnaire was also predictive of risk factors and clinical and lipid profile measurements. CONCLUSIONS In asymptomatic patients, self-reported exercise is a significant predictor of long-term outcomes. Prognostic value of the reported exercise is additive to the increasing degree of underlying atherosclerosis. Among patients with high CAC scores, exercise may play a protective role, whereas reported minimal or no exercise substantially increases clinical risk. Our results suggest there is clinical utility for the use of a simple single-item exercise questionnaire for such assessments.
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Affiliation(s)
- Yoav Arnson
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Heidi Gransar
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sean W Hayes
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - John D Friedman
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Louise E J Thomson
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Berman
- Department of Imaging, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Shalev A, Nakazato R, Arsanjani R, Nakanishi R, Park HB, Otaki Y, Cheng VY, Gransar H, LaBounty TM, Hayes SW, Berman DS, Min JK. SYNTAX Score Derived From Coronary CT Angiography for Prediction of Complex Percutaneous Coronary Interventions. Acad Radiol 2016; 23:1384-1392. [PMID: 27658330 DOI: 10.1016/j.acra.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/07/2016] [Accepted: 07/15/2016] [Indexed: 12/23/2022]
Abstract
RATIONALE AND OBJECTIVES SYNTAX score is a useful metric determined at the time of invasive coronary angiography (ICA) to assess the complexity of coronary artery disease, and improves prediction of complications at the time of percutaneous complex intervention (PCI). We aimed to determine whether SYNTAX score can be reliably determined from coronary computed tomography angiography (CCTA) and whether a CCTA-derived SYNTAX score can predict complex PCI. MATERIALS AND METHODS SYNTAX scores were calculated on per-patient, per-vessel, and per-segment basis in 154 consecutive patients who underwent CCTA and ICA. PCI complexity in 113 patients who underwent intervention was defined by total fluoroscopy time and contrast volume. RESULTS Compared to ICA, CCTA detected 285 of 302 (94%) obstructive lesions in 230 vessels, for which PCI was performed for 154 lesions in 131 vessels. Overall, on a per-patient basis, ICA-derived SYNTAX score was lower in comparison to CCTA-derived score (10.2 ± 8.0 vs 10.9 ± 8.3, P = 0.001). As compared to lesions in the lowest CCTA-derived segmental SYNTAX tertile, lesions in the highest tertile required longer fluoroscopy time (17.5 ± 12 min vs 11.5 ± 7.9 min, P = 0.01) and greater contrast volume (215.4 ± 125.5 mL vs 144.3 ± 49 mL, P = 0.02). CONCLUSION SYNTAX scores derived from CCTA are concordant with those derived from ICA and correspond with complex PCI.
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Affiliation(s)
- Aryeh Shalev
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Ryo Nakazato
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Reza Arsanjani
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Rine Nakanishi
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Hyung-Bok Park
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Yuka Otaki
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Heidi Gransar
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Troy M LaBounty
- Departments of Medicine and Radiology, University of Michigan, Ann Harbor, Michigan
| | - Sean W Hayes
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Daniel S Berman
- Departments of Imaging (Division of Nuclear Medicine) and Medicine (Division of Cardiology), Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, Los Angeles, California; Department of Medicine, David Geffen UCLA School of Medicine, University of California Los Angeles, Los Angeles, California
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, NewYork-Presbyterian Hospital, 413 E 69th Street, BRB 108, New York, NY 10021.
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Nakanishi R, Gransar H, Slomka P, Arsanjani R, Shalev A, Otaki Y, Friedman JD, Hayes SW, Thomson LEB, Fish M, Germano G, Abidov A, Shaw L, Rozanski A, Berman DS. Predictors of high-risk coronary artery disease in subjects with normal SPECT myocardial perfusion imaging. J Nucl Cardiol 2016; 23:530-41. [PMID: 25971987 PMCID: PMC6377163 DOI: 10.1007/s12350-015-0150-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/30/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND While uncommon, normal stress SPECT myocardial perfusion imaging (MPI) can be seen in patients with high-risk coronary artery disease (CAD) by invasive coronary angiography (ICA).The predictors of high-risk CAD in patients with normal SPECT-MPI have not been described. METHODS We studied 580 patients (age 64 ± 12 years, 49% men) without known CAD who underwent stress-gated SPECT-MPI [exercise (41%) or vasodilator (59%)] <2 months before ICA and had summed stress score (SSS) <4. High-risk CAD was defined as 3 vessels with ≥70% stenosis, 2 vessels with ≥70% stenosis including proximal left anterior descending, or left main with ≥50% stenosis. Obstructive non-high-risk CAD was defined by the presence of a ≥70% stenosis but without having other high-risk criteria. Tenfold cross-validated receiver operating characteristic (ROC) estimates were obtained to assess the predictors of high-risk CAD. RESULTS Forty-two subjects (7.2%) had high-risk CAD and 168 (29.0%) had obstructive non-high-risk CAD. Variables associated with high-risk CAD were pretest probability of CAD ≥66% (Odds ratio [OR] 3.63, 95% CI 1.6-8.3, P = .002), SSS > 0 (OR 7.46, 95% CI 2.6-21.1, P < 0.001), and abnormal TID (OR 2.16, 95% CI 1.0-4.5, P = 0.044). When substituted for TID, EF change was also predictive of high-risk CAD (OR 0.93, 95% CI 0.9-1.0, P = 0.023). The prevalence of high-risk CAD increased as the number of these predictors increased. In a sub-analysis of patients in whom quantitative total perfusion deficit (TPD) was available, TPD > 0 was also a predictor of high-risk CAD (OR 6.01, 95% CI 1.5-22.2, P = 0.011). CONCLUSION Several clinical, stress, and SPECT-MPI findings are associated high-risk CAD among patients with normal SPECT-MPI. Consideration of these factors may improve the overall assessment of the likelihood of high-risk CAD in patients undergoing stress SPECT-MPI.
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Affiliation(s)
- Rine Nakanishi
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Heidi Gransar
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Piotr Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Reza Arsanjani
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Aryeh Shalev
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Yuka Otaki
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - John D Friedman
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Sean W Hayes
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Louise E B Thomson
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Mathews Fish
- Oregon Heart and Vascular Institute, Sacred Heart Medical Center, Springfield, OR, USA
| | - Guido Germano
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Aiden Abidov
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Leslee Shaw
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Alan Rozanski
- Division of Cardiology, St. Luke's Roosevelt Hospital, New York, NY, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA.
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Arbit B, Azarbal B, Hayes SW, Gransar H, Germano G, Friedman JD, Thomson L, Berman DS. Prognostic Contribution of Exercise Capacity, Heart Rate Recovery, Chronotropic Incompetence, and Myocardial Perfusion Single-Photon Emission Computerized Tomography in the Prediction of Cardiac Death and All-Cause Mortality. Am J Cardiol 2015; 116:1678-84. [PMID: 26482180 DOI: 10.1016/j.amjcard.2015.08.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 11/19/2022]
Abstract
Chronotropic incompetence, measured by the percentage (%) of heart rate (HR) reserve achieved (%HR reserve), abnormal HR recovery, reduced exercise capacity (EC), and myocardial perfusion single-photon emission computerized tomography (SPECT MPS) abnormalities are known predictors of all-cause mortality (ACM) and cardiac death (CD). The aim of this study was to determine if EC, %HR reserve, and HR recovery add incremental value to MPS in the prediction of ACM and CD. A total of 11,218 patients without valvular disease and not on β blockers underwent symptom-limited exercise MPS. %HR reserve was (peak HR - rest HR)/(220 - age - rest HR) × 100, with %HR reserve <80 defined as low. HR recovery was peak HR - recovery HR. An HR recovery <22 beats/min at 2 minutes after peak exercise was considered abnormal. Poor EC was defined as exercise duration ≤6 minutes (7 metabolic equivalents). Summed stress scores (SSSs) were calculated using a 20-segment, 5-point MPS model. Statistical analysis was performed using Cox regression models. There were 445 deaths (148 CD) during a mean follow-up of 3.2 ± 2.5 years. In multivariate analysis, the independent predictors of ACM were age, χ(2) = 154.81; EC, χ(2) = 74.00; SSS, χ(2) = 32.99; %HR reserve, χ(2) = 24.74; abnormal electrocardiogram at rest, χ(2) = 23.13; HR recovery, χ(2) = 18.45; diabetes, χ(2) = 17.75; and previous coronary artery disease, χ(2) = 11.85 (p ≤0.0006). The independent predictors of CD were SSS, χ(2) = 54.25; EC, χ(2) = 49.34; age, χ(2) = 46.45; abnormal electrocardiogram at rest, χ(2) = 30.60; previous coronary artery disease, χ(2) = 20.69; Duke treadmill score, χ(2) = 19.50; %HR reserve, χ(2) = 11.43; diabetes, χ(2) = 10.23 (all p ≤0.0014); and HR recovery, χ(2) = 5.30 (p = 0.0214). The exercise variables showed increases in Harrell's C static and net improvement reclassification, with EC showing the strongest incremental improvement in predicting ACM and CD (respective C-index 76.5% and 83.3% and net reclassification index 0.3201 and 0.4996). In conclusion, EC, %HR reserve, and HR recovery are independent predictors of ACM and CD and add incremental prognostic value to extent and severity of MPS.
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Affiliation(s)
- Boris Arbit
- Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, California
| | - Babak Azarbal
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Sean W Hayes
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Heidi Gransar
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Guido Germano
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California
| | - John D Friedman
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Louise Thomson
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Daniel S Berman
- Cedars-Sinai Heart Institute, Cedars-Sinai, Los Angeles, California.
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Arsanjani R, Dey D, Khachatryan T, Shalev A, Hayes SW, Fish M, Nakanishi R, Germano G, Berman DS, Slomka P. Prediction of revascularization after myocardial perfusion SPECT by machine learning in a large population. J Nucl Cardiol 2015; 22:877-84. [PMID: 25480110 PMCID: PMC4859156 DOI: 10.1007/s12350-014-0027-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/16/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVE We aimed to investigate if early revascularization in patients with suspected coronary artery disease can be effectively predicted by integrating clinical data and quantitative image features derived from perfusion SPECT (MPS) by machine learning (ML) approach. METHODS 713 rest (201)Thallium/stress (99m)Technetium MPS studies with correlating invasive angiography with 372 revascularization events (275 PCI/97 CABG) within 90 days after MPS (91% within 30 days) were considered. Transient ischemic dilation, stress combined supine/prone total perfusion deficit (TPD), supine rest and stress TPD, exercise ejection fraction, and end-systolic volume, along with clinical parameters including patient gender, history of hypertension and diabetes mellitus, ST-depression on baseline ECG, ECG and clinical response during stress, and post-ECG probability by boosted ensemble ML algorithm (LogitBoost) to predict revascularization events. These features were selected using an automated feature selection algorithm from all available clinical and quantitative data (33 parameters). Tenfold cross-validation was utilized to train and test the prediction model. The prediction of revascularization by ML algorithm was compared to standalone measures of perfusion and visual analysis by two experienced readers utilizing all imaging, quantitative, and clinical data. RESULTS The sensitivity of machine learning (ML) (73.6% ± 4.3%) for prediction of revascularization was similar to one reader (73.9% ± 4.6%) and standalone measures of perfusion (75.5% ± 4.5%). The specificity of ML (74.7% ± 4.2%) was also better than both expert readers (67.2% ± 4.9% and 66.0% ± 5.0%, P < .05), but was similar to ischemic TPD (68.3% ± 4.9%, P < .05). The receiver operator characteristics areas under curve for ML (0.81 ± 0.02) was similar to reader 1 (0.81 ± 0.02) but superior to reader 2 (0.72 ± 0.02, P < .01) and standalone measure of perfusion (0.77 ± 0.02, P < .01). CONCLUSION ML approach is comparable or better than experienced readers in prediction of the early revascularization after MPS, and is significantly better than standalone measures of perfusion derived from MPS.
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Affiliation(s)
- Reza Arsanjani
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA.
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Damini Dey
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Tigran Khachatryan
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
| | - Aryeh Shalev
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
| | - Sean W Hayes
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
| | - Mathews Fish
- Oregon Heart and Vascular Institute, Sacred Heart Medical Center, Springfield, OR, USA
| | - Rine Nakanishi
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
| | - Guido Germano
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel S Berman
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Piotr Slomka
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Taper A238, Los Angeles, CA, 90048, USA.
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Artificial Intelligence in Medicine Program, 8700 Beverly Blvd, Ste A047N, Los Angeles, CA, 90048, USA.
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Min JK, Dunning A, Gransar H, Achenbach S, Lin FY, Al-Mallah M, Budoff MJ, Callister TQ, Chang HJ, Cademartiri F, Maffei E, Chinnaiyan K, Chow BJW, D'Agostino R, DeLago A, Friedman J, Hadamitzky M, Hausleiter J, Hayes SW, Kaufmann P, Raff GL, Shaw LJ, Thomson L, Villines T, Cury RC, Feuchtner G, Kim YJ, Leipsic J, Marques H, Berman DS, Pencina M. Medical history for prognostic risk assessment and diagnosis of stable patients with suspected coronary artery disease. Am J Med 2015; 128:871-8. [PMID: 25865923 PMCID: PMC4516558 DOI: 10.1016/j.amjmed.2014.10.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/17/2014] [Accepted: 10/17/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To develop a clinical cardiac risk algorithm for stable patients with suspected coronary artery disease based upon angina typicality and coronary artery disease risk factors. METHODS Between 2004 and 2011, 14,004 adults with suspected coronary artery disease referred for cardiac imaging were followed: 1) 9093 patients for coronary computed tomography angiography (CCTA) followed for 2.0 years (CCTA-1); 2) 2132 patients for CCTA followed for 1.6 years (CCTA-2); and 3) 2779 patients for exercise myocardial perfusion scintigraphy (MPS) followed for 5.0 years. A best-fit model from CCTA-1 for prediction of death or myocardial infarction was developed, with integer values proportional to regression coefficients. Discrimination was assessed using C-statistic. The validated model was tested for estimation of the likelihood of obstructive coronary artery disease, defined as ≥50% stenosis, as compared with the method of Diamond and Forrester. Primary outcomes included all-cause mortality and nonfatal myocardial infarction. Secondary outcomes included prevalent angiographically obstructive coronary artery disease. RESULTS In CCTA-1, best-fit model discriminated individuals at risk of death or myocardial infarction (C-statistic 0.76). The integer model ranged from 3 to 13, corresponding to 3-year death risk or myocardial infarction of 0.25% to 53.8%. When applied to CCTA-2 and MPS cohorts, the model demonstrated C-statistics of 0.71 and 0.77, respectively. Both best-fit (C = 0.76; 95% confidence interval [CI], 0.746-0.771) and integer models (C = 0.71; 95% CI, 0.693-0.719) performed better than Diamond and Forrester (C = 0.64; 95% CI, 0.628-0.659) for estimating obstructive coronary artery disease. CONCLUSIONS For stable symptomatic patients with suspected coronary artery disease, we developed a history-based method for prediction of death and obstructive coronary artery disease.
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Affiliation(s)
- James K Min
- Department of Radiology, Weill Cornell Medical College and the New York-Presbyterian Hospital, New York.
| | - Allison Dunning
- Department of Public Health, Weill Cornell Medical College and the New York-Presbyterian Hospital, New York
| | - Heidi Gransar
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, Calif
| | | | - Fay Y Lin
- Department of Medicine, Weill Cornell Medical College and the New York-Presbyterian Hospital, New York
| | - Mouaz Al-Mallah
- Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, Mich
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, Calif
| | | | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea
| | - Filippo Cademartiri
- Cardiovascular Radiology Unit, Giovanni XXIII Hospital, Monastier di Treviso, Italy; Department of Radiology and Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Erica Maffei
- Cardiovascular Radiology Unit, Giovanni XXIII Hospital, Monastier di Treviso, Italy; Department of Radiology and Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Benjamin J W Chow
- Department of Medicine and Radiology, University of Ottawa Heart Institute, Ontario, Canada
| | | | | | - John Friedman
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Martin Hadamitzky
- Division of Cardiology, Deutsches Herzzentrum München, Munich, Germany
| | - Joerg Hausleiter
- Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Sean W Hayes
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, Calif
| | | | | | - Leslee J Shaw
- Department of Medicine, Emory University School of Medicine, Atlanta, Ga
| | - Louise Thomson
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Todd Villines
- Department of Medicine, Walter Reed Medical Center, Washington, DC
| | | | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Yong-Jin Kim
- Department of Medicine and Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Jonathon Leipsic
- Division of Cardiology and Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | | | - Daniel S Berman
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Michael Pencina
- Department of Biostatistics, Boston University and Harvard Clinical Research Institute, Boston, Mass
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Brodov Y, Gransar H, Dey D, Shalev A, Germano G, Friedman JD, Hayes SW, Thomson LE, Rogatko A, Berman DS, Slomka PJ. Combined Quantitative Assessment of Myocardial Perfusion and Coronary Artery Calcium Score by Hybrid 82Rb PET/CT Improves Detection of Coronary Artery Disease. J Nucl Med 2015; 56:1345-50. [DOI: 10.2967/jnumed.114.153429] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 06/02/2015] [Indexed: 01/12/2023] Open
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Nakazato R, Slomka PJ, Fish M, Schwartz RG, Hayes SW, Thomson LE, Friedman JD, Lemley M, Mackin ML, Peterson B, Schwartz AM, Doran JA, Germano G, Berman DS. Quantitative high-efficiency cadmium-zinc-telluride SPECT with dedicated parallel-hole collimation system in obese patients: results of a multi-center study. J Nucl Cardiol 2015; 22:266-75. [PMID: 25388380 PMCID: PMC4355061 DOI: 10.1007/s12350-014-9984-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Obesity is a common source of artifact on conventional SPECT myocardial perfusion imaging (MPI). We evaluated image quality and diagnostic performance of high-efficiency (HE) cadmium-zinc-telluride parallel-hole SPECT MPI for coronary artery disease (CAD) in obese patients. METHODS AND RESULTS 118 consecutive obese patients at three centers (BMI 43.6 ± 8.9 kg·m(-2), range 35-79.7 kg·m(-2)) had upright/supine HE-SPECT and invasive coronary angiography > 6 months (n = 67) or low likelihood of CAD (n = 51). Stress quantitative total perfusion deficit (TPD) for upright (U-TPD), supine (S-TPD), and combined acquisitions (C-TPD) was assessed. Image quality (IQ; 5 = excellent; < 3 nondiagnostic) was compared among BMI 35-39.9 (n = 58), 40-44.9 (n = 24) and ≥45 (n = 36) groups. ROC curve area for CAD detection (≥50% stenosis) for U-TPD, S-TPD, and C-TPD were 0.80, 0.80, and 0.87, respectively. Sensitivity/specificity was 82%/57% for U-TPD, 74%/71% for S-TPD, and 80%/82% for C-TPD. C-TPD had highest specificity (P = .02). C-TPD normalcy rate was higher than U-TPD (88% vs 75%, P = .02). Mean IQ was similar among BMI 35-39.9, 40-44.9 and ≥45 groups [4.6 vs 4.4 vs 4.5, respectively (P = .6)]. No patient had a nondiagnostic stress scan. CONCLUSIONS In obese patients, HE-SPECT MPI with dedicated parallel-hole collimation demonstrated high image quality, normalcy rate, and diagnostic accuracy for CAD by quantitative analysis of combined upright/supine acquisitions.
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Affiliation(s)
- Ryo Nakazato
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA
- Cardiovascular Center, St Luke’s International Hospital, Tokyo, Japan
| | - Piotr J. Slomka
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mathews Fish
- Department of Cardiology, Peacehealth Sacred Heart Medical Center, Springfield, OR
| | - Ronald G. Schwartz
- Departments of Medicine (Cardiology Division) and Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - Sean W. Hayes
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - John D. Friedman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark Lemley
- Department of Cardiology, Peacehealth Sacred Heart Medical Center, Springfield, OR
| | - Maria L. Mackin
- Departments of Medicine (Cardiology Division) and Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - Benjamin Peterson
- Departments of Medicine (Cardiology Division) and Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - Arielle M. Schwartz
- Departments of Medicine (Cardiology Division) and Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - Jesse A. Doran
- Departments of Medicine (Cardiology Division) and Imaging Sciences, University of Rochester Medical Center, Rochester, NY
| | - Guido Germano
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Daniel S. Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA
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Brodov Y, Gransar H, Rozanski A, Hayes SW, Friedman JD, Thomson LEJ, Dey D, Slomka PJ, Min JK, Shaw LJ, Shah PK, Germano G, Berman DS. Extensive thoracic aortic calcification is an independent predictor of development of coronary artery calcium among individuals with coronary artery calcium score of zero. Atherosclerosis 2014; 238:4-8. [PMID: 25461732 DOI: 10.1016/j.atherosclerosis.2014.10.100] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/21/2014] [Accepted: 10/24/2014] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The predictive value of thoracic aortic calcium (TAC) scores for coronary artery calcium (CAC) conversion (CAC>0) has not been fully evaluated. METHODS We studied 1648 asymptomatic subjects (mean age 52 ± 9 years, 54% male) with baseline CAC = 0 who underwent repeat CAC scanning 5 years later (range 3-14 years). TAC was assessed in the ascending and descending aorta. CAC and TAC were measured using Agatston scores. The cohort was categorized by baseline TAC scores: TAC = 0 (n = 1381 subjects), TAC 1-9 (n = 54), TAC 10-99 (n = 132) and TAC≥100 (n = 81). Logistic regression was used to examine the predictive value of baseline TAC scores for CAC>0 on repeat scans. RESULTS On repeat scanning, 380 subjects (23%) developed CAC>0. The frequency of CAC>0 increased progressively across baseline TAC (TAC = 0, TAC 1-9, TAC 10-99 and TAC≥100) 22%, 26%, 26% and 37%, respectively (P for trend = 0.0025). Univariate analysis showed baseline TAC ≥100 was a significant predictor of CAC>0 in repeat scans, while either TAC 1-9 or TAC 10-99 were not, OR 2.10 [CI 1.32-3.36], P = 0.002; OR 1.25 [CI 0.67-2.33], P = 0.5; OR 1.24 [CI 0.82-1.87], P = 0.3, respectively. In multivariable analysis, TAC ≥100 OR 1.90 [CI 1.08-3.33], P = 0.026, was a significant predictor of CAC>0, along with age, male gender, diabetes, hypertension, hypercholesterolemia and time between scans. CONCLUSIONS The likelihood of conversion to CAC>0 increases with increasing TAC scores. TAC ≥ 100 is an independent predictor of CAC conversion. Subjects with CAC = 0 and extensive TAC (TAC ≥ 100) may merit earlier repeat scanning than those with no TAC or lower TAC scores.
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Affiliation(s)
- Yafim Brodov
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Heidi Gransar
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alan Rozanski
- Division of Cardiology, St. Lukes Roosevelt Hospital, New York, NY, USA
| | - Sean W Hayes
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - John D Friedman
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Louise E J Thomson
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Damini Dey
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Biomedical Sciences and Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, CA, USA
| | - Piotr J Slomka
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - James K Min
- Department of Radiology and Medicine Weill Cornell Medical College, New York, NY, USA
| | - Leslee J Shaw
- Emory Clinical Cardiovascular Research Institute (ECCRI), Emory University School of Medicine, Atlanta, GA, USA
| | - P K Shah
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Guido Germano
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel S Berman
- Department of Cardiac Imaging (Division of Nuclear Medicine), The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Cardiology, The Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Arsanjani R, Hayes SW, Fish M, Shalev A, Nakanishi R, Thomson LEJ, Friedman JD, Germano G, Berman DS, Slomka P. Two-position supine/prone myocardial perfusion SPECT (MPS) imaging improves visual inter-observer correlation and agreement. J Nucl Cardiol 2014; 21:703-11. [PMID: 24807622 PMCID: PMC4158826 DOI: 10.1007/s12350-014-9895-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We aimed to compare the inter-observer agreement between two experienced readers using supine vs combined supine/prone myocardial perfusion SPECT (MPS) in a large population. METHODS 1,181 consecutive patients without known coronary artery disease (CAD) undergoing rest (201)Tl/stress (99m)Tc-sestamibi MPS studies were evaluated. Visual reads were performed in two consecutive steps, with readers scoring the stress supine perfusion images during step 1 and rescoring the images using both supine/prone data during step 2. Visual summed stress scores (SSS) of two readers including regional scores in different vascular territories were compared. RESULTS The specificity for both readers improved using combined supine/prone imaging (reader 1: 92% vs 86% [P = .0002], reader 2: 88% vs 72% [P < .0001]). The inter-observer correlation for SSS (0.90 vs 0.84, P < .0001) and inter-observer agreement for combined supine/prone reading (bias = 1.0, 95% confidence interval (CI) 0.9-1.2 vs bias = 3.1, 95% CI 2.8-3.4, P < .0001) were significantly better as compared to supine-only reading. The overall correlation between SSS scores for two readers improved with supine/prone imaging for both genders, as well as in the left anterior descending and right coronary territories. CONCLUSION The inter-observer correlation and agreement significantly improve using two-position supine/prone vs supine-only imaging.
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Affiliation(s)
- Reza Arsanjani
- Departments of Imaging and Medicine, and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA,
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Einstein AJ, Blankstein R, Andrews H, Fish M, Padgett R, Hayes SW, Friedman JD, Qureshi M, Rakotoarivelo H, Slomka P, Nakazato R, Bokhari S, Di Carli M, Berman DS. Comparison of image quality, myocardial perfusion, and left ventricular function between standard imaging and single-injection ultra-low-dose imaging using a high-efficiency SPECT camera: the MILLISIEVERT study. J Nucl Med 2014; 55:1430-7. [PMID: 24982439 DOI: 10.2967/jnumed.114.138222] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED SPECT myocardial perfusion imaging plays a central role in coronary artery disease diagnosis, but concerns exist regarding its radiation burden. Compared with standard Anger SPECT (A-SPECT) cameras, new high-efficiency (HE) cameras with specialized collimators and solid-state cadmium-zinc-telluride detectors offer potential to maintain image quality (IQ), while reducing administered activity and thus radiation dose to patients. No previous study has compared IQ, interpretation, total perfusion deficit (TPD), or ejection fraction (EF) in patients receiving both ultra-low-dose (ULD) imaging on an HE SPECT camera and standard low-dose (SLD) A-SPECT imaging. METHODS We compared ULD HE SPECT with SLD A-SPECT imaging by dividing the rest dose in 101 patients at 3 sites scheduled to undergo clinical A-SPECT myocardial perfusion imaging using a same day rest-stress (99m)Tc protocol. Patients underwent HE SPECT imaging after an initial approximately 130-MBq (3.5 mCi) dose and SLD-A-SPECT imaging after the remainder of the planned dose. Images were scored visually by 2 masked readers for IQ and summed rest score. TPD and EF were assessed quantitatively. RESULTS Mean activity was 134 MBq (3.62 mCi) for ULD HE SPECT (effective dose, 1.15 mSv) and 278 MBq (7.50 mCi, 2.39 mSv) for SLD A-SPECT. Overall IQ was superior for ULD HE SPECT (P < 0.0001), with twice as many studies graded excellent quality. Extracardiac activity and overall perfusion assessment were similar. Between-method correlations were high for summed rest score (r = 0.87), TPD (r = 0.91), and EF (r = 0.88). CONCLUSION ULD HE SPECT rest imaging correlates highly with SLD A-SPECT. It has improved image quality, comparable extracardiac activity, and achieves radiation dose reduction to 1 mSv for a single injection.
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Affiliation(s)
- Andrew J Einstein
- Department of Medicine, Cardiology Division, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Ron Blankstein
- Department of Medicine, Cardiology Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Howard Andrews
- Department of Biostatistics, Columbia University, New York, New York
| | - Mathews Fish
- Oregon Heart and Vascular Institute, Springfield, Oregon
| | | | - Sean W Hayes
- Departments of Imaging and Medicine and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; and
| | - John D Friedman
- Departments of Imaging and Medicine and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; and
| | - Mehreen Qureshi
- Department of Medicine, Cardiology Division, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Harivony Rakotoarivelo
- Department of Medicine, Cardiology Division, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Piotr Slomka
- Departments of Imaging and Medicine and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ryo Nakazato
- Departments of Imaging and Medicine and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
| | - Sabahat Bokhari
- Department of Medicine, Cardiology Division, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York
| | - Marcello Di Carli
- Department of Medicine, Cardiology Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel S Berman
- Departments of Imaging and Medicine and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; and
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Rozanski A, Gransar H, Min JK, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Long-term mortality following normal exercise myocardial perfusion SPECT according to coronary disease risk factors. J Nucl Cardiol 2014; 21:341-50. [PMID: 24379127 DOI: 10.1007/s12350-013-9830-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 11/17/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND While normal exercise myocardial perfusion imaging (SPECT-MPI) is a robust predictor of low short-term clinical risk, there is increasing interest in ascertaining how clinical factors influence long-term risk following SPECT-MPI. METHODS We evaluated the predictors of outcome from clinical data obtained at the time of testing in 12,232 patients with normal exercise SPECT-MPI studies. All-cause mortality (ACM) was assessed at a mean of 11.2 ± 4.5 years using the Social Security Death Index. RESULTS The ACM rate was 0.8%/year, but varied markedly according to the presence of CAD risk factors. Hypertension, smoking, diabetes, exercise capacity, dyspnea, obesity, higher resting heart rate, an abnormal ECG, LVH, atrial fibrillation, and LVEF < 45% were all predictors of increased mortality. Risk factors were synergistic in predicting mortality: annualized age and gender-adjusted ACM rates ranged from only 0.2%/year among patients exercising for >9 minutes having none of three significant risk factors (among hypertension, diabetes, and smoking) to 1.6%/year among patients exercising <6 minutes and having ≥ 2 of these three risk factors. The age and gender-adjusted hazard ratio for mortality was increased by 7.3 (95% confidence interval 5.5-9.7) in the latter patients compared to those patients who exercised >9 minutes and had no significant risk factors (P < .001). CONCLUSIONS Long-term mortality risk varies markedly in accordance with baseline CAD risk factors and functional capacity among patients with normal exercise SPECT-MPI studies. Further study is indicated to determine whether the prospective characterization of both short-term and long-term risks following the performance of stress SPECT-MPI leads to improved clinical management.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology, St. Lukes Roosevelt Hospital, New York, NY, USA,
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Mancini GBJ, Hartigan PM, Shaw LJ, Berman DS, Hayes SW, Bates ER, Maron DJ, Teo K, Sedlis SP, Chaitman BR, Weintraub WS, Spertus JA, Kostuk WJ, Dada M, Booth DC, Boden WE. Predicting outcome in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation): coronary anatomy versus ischemia. JACC Cardiovasc Interv 2014; 7:195-201. [PMID: 24440015 DOI: 10.1016/j.jcin.2013.10.017] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/12/2013] [Accepted: 10/24/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to determine the relative utility of anatomic and ischemic burden of coronary artery disease for predicting outcomes. BACKGROUND Both anatomic burden and ischemic burden of coronary artery disease determine patient prognosis and influence myocardial revascularization decisions. When both measures are available, their relative utility for prognostication and management choice is controversial. METHODS A total of 621 patients enrolled in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial with baseline quantitative nuclear single-photon emission computed tomography (SPECT) and quantitative coronary angiography were studied. Several multiple regression models were constructed to determine independent predictors of the endpoint of death, myocardial infarction (MI) (excluding periprocedural MI) and non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Ischemic burden during stress SPECT, anatomic burden derived from angiography, left ventricular ejection fraction, and assignment to either optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) or OMT alone were analyzed. RESULTS In nonadjusted and adjusted regression models, anatomic burden and left ventricular ejection fraction were consistent predictors of death, MI, and NSTE-ACS, whereas ischemic burden and treatment assignment were not. There was a marginal (p = 0.03) effect of the interaction term of anatomic and ischemic burden for the prediction of clinical outcome, but separately or in combination, neither anatomy nor ischemia interacted with therapeutic strategy to predict outcome. CONCLUSIONS In a cohort of patients treated with OMT, anatomic burden was a consistent predictor of death, MI, and NSTE-ACS, whereas ischemic burden was not. Importantly, neither determination, even in combination, identified a patient profile benefiting preferentially from an invasive therapeutic strategy. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).
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Affiliation(s)
- G B John Mancini
- University of British Columbia, Vancouver, British Columbia, Canada.
| | - Pamela M Hartigan
- Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, Connecticut
| | - Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia
| | - Daniel S Berman
- Cedars-Sinai Heart Institute, University of California, Los Angeles, California
| | - Sean W Hayes
- Cedars-Sinai Heart Institute, University of California, Los Angeles, California
| | - Eric R Bates
- University of Michigan Medical Center, Ann Arbor, Michigan
| | - David J Maron
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Koon Teo
- McMaster University Medical Center, Hamilton, Ontario, Canada
| | - Steven P Sedlis
- VA New York Harbor Healthcare System, New York Campus, New York University School of Medicine, New York, New York
| | | | | | - John A Spertus
- Mid America Heart Institute, University of Missouri, Kansas City, Missouri
| | - William J Kostuk
- London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | | | | | - William E Boden
- New York Health Care System, Buffalo General Hospital and the State University of New York at Buffalo, Buffalo, New York
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Phillips LM, Hachamovitch R, Berman DS, Iskandrian AE, Min JK, Picard MH, Kwong RY, Friedrich MG, Scherrer-Crosbie M, Hayes SW, Sharir T, Gosselin G, Mazzanti M, Senior R, Beanlands R, Smanio P, Goyal A, Al-Mallah M, Reynolds H, Stone GW, Maron DJ, Shaw LJ. Lessons learned from MPI and physiologic testing in randomized trials of stable ischemic heart disease: COURAGE, BARI 2D, FAME, and ISCHEMIA. J Nucl Cardiol 2013; 20:969-75. [PMID: 23963599 PMCID: PMC3954506 DOI: 10.1007/s12350-013-9773-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
There is a preponderance of evidence that, in the setting of an acute coronary syndrome, an invasive approach using coronary revascularization has a morbidity and mortality benefit. However, recent stable ischemic heart disease (SIHD) randomized clinical trials testing whether the addition of coronary revascularization to guideline-directed medical therapy (GDMT) reduces death or major cardiovascular events have been negative. Based on the evidence from these trials, the primary role of GDMT as a front line medical management approach has been clearly defined in the recent SIHD clinical practice guideline; the role of prompt revascularization is less precisely defined. Based on data from observational studies, it has been hypothesized that there is a level of ischemia above which a revascularization strategy might result in benefit regarding cardiovascular events. However, eligibility for recent negative trials in SIHD has mandated at most minimal standards for ischemia. An ongoing randomized trial evaluating the effectiveness of randomization of patients to coronary angiography and revascularization as compared to no coronary angiography and GDMT in patients with moderate-severe ischemia will formally test this hypothesis. The current review will highlight the available evidence including a review of the published and ongoing SIHD trials.
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Affiliation(s)
- Lawrence M Phillips
- New York University School of Medicine, 530 First Avenue, SKI-9U, New York, NY, 10016, USA,
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Nakanishi R, Rana JS, Rozanski A, Cheng VY, Gransar H, Thomson LE, Miranda-Peats R, Hayes SW, Friedman JD, Berman DS, Min JK. Relationship of dyspnea vs. typical angina to coronary artery disease severity, burden, composition and location on coronary CT angiography. Atherosclerosis 2013; 230:61-6. [DOI: 10.1016/j.atherosclerosis.2013.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 04/12/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
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Nakanishi R, Rana JS, Shalev A, Gransar H, Hayes SW, Labounty TM, Dey D, Miranda-Peats R, Thomson LE, Friedman JD, Abidov A, Min JK, Berman DS. Mortality risk as a function of the ratio of pulmonary trunk to ascending aorta diameter in patients with suspected coronary artery disease. Am J Cardiol 2013; 111:1259-63. [PMID: 23415638 DOI: 10.1016/j.amjcard.2013.01.266] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 01/07/2013] [Accepted: 01/07/2013] [Indexed: 01/07/2023]
Abstract
Although an increased pulmonary trunk (PT) diameter to ascending aorta (AA) diameter ratio (PT/AA ratio) is associated with pulmonary hypertension, the prognostic utility of this metric remains unexamined. We investigated whether an increase in the PT/AA ratio, as measured using coronary computed tomographic angiography, is associated with the risk of all-cause death. We identified 1,326 consecutive patients (mean age 61 ± 13 years; 60% men) without known coronary artery disease who underwent coronary computed tomographic angiography. Patients with a history of congenital or valvular heart disease or aortic enlargement (≥4 cm) were excluded. The PT and AA diameters were measured at the PT bifurcation level. The patients were categorized by PT/AA deciles, with the ≥90th percentile (PT/AA ratio 0.9) considered elevated. All-cause death associated with a PT/AA ratio <0.9 versus ≥0.9 was evaluated using multivariate Cox proportional hazard models. During 2.9 ± 1.0 years of follow-up, 58 patients died. Patients with a PT/AA ratio ≥0.9 experienced 2.5-fold greater annualized mortality compared to those with <0.9 (3.1% vs 1.3%, p = 0.004). Adjusting for age, gender, heart rate, dyslipidemia, smoking, and coronary artery disease extent, the patients with a PT/AA ratio ≥0.9 experienced a greater mortality risk compared to patients with PT/AA ratio <0.9 (hazard ratio 3.2, 95% confidence interval 1.6 to 6.6, p = 0.001). In the 1,059 patients with left ventricular ejection fraction measurements, a lower left ventricular ejection fraction was observed in the PT/AA ratio ≥0.9 group (p <0.05). In conclusion, incrementally and independent of the traditional coronary artery disease risk factors, an elevated PT/AA ratio was associated with increased mortality risk in patients without known coronary artery disease undergoing coronary computed tomographic angiography.
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Rajani R, Shmilovich H, Nakazato R, Nakanishi R, Otaki Y, Cheng VY, Hayes SW, Thomson LEJ, Friedman JD, Slomka PJ, Min JK, Berman DS, Dey D. Relationship of epicardial fat volume to coronary plaque, severe coronary stenosis, and high-risk coronary plaque features assessed by coronary CT angiography. J Cardiovasc Comput Tomogr 2013; 7:125-32. [PMID: 23622507 DOI: 10.1016/j.jcct.2013.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [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] [Received: 11/08/2012] [Revised: 01/15/2013] [Accepted: 02/21/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Associations of epicardial fat volume (EFV) measured on noncontrast cardiac CT (NCT) include coronary plaque, myocardial ischemia, and adverse cardiac events. OBJECTIVES This study aimed to define the relationship of EFV to coronary plaque type, severe coronary stenosis, and the presence of high-risk plaque features (HRPFs). METHODS We retrospectively evaluated 402 consecutive patients, with no prior history of coronary artery disease, who underwent same day NCT and coronary CT angiography (CTA). EFV was measured on NCT with the use of validated, semiautomated software. The coronary arteries were evaluated for coronary plaque type (calcified [CP], noncalcified [NCP], or partially calcified [PCP]) and coronary stenosis severity ≥70% with the use of coronary CTA. For patients with NCP and PCP, 2 high-risk plaque features were evaluated: low-attenuation plaque and positive remodeling. RESULTS There were 402 patients with a median age of 66 years (range, 23-92 years) of whom 226 (56%) were men. The EFV was greater in patients with CP (112 ± 55 cm(3) vs 89 ± 39 cm(3)), PCP (110 ± 57 cm(3) vs 98 ± 45 cm(3)), and NCP (115 ± 44 cm(3) vs EFV 100 ± 52 cm(3)). In the 192 patients with PCP or NCP, on multivariable analysis, after adjusting for conventional cardiovascular risk factors, EFV was an independent predictor of ≥70% coronary artery stenosis (odds ratio [OR], 3.0; 95% CI, 1.3-6.6; P = 0.008), any high-risk plaque features (OR, 1.7; 95% CI, 0.9-3.4; P = 0.04), and low attention plaque (OR, 2.4; 95% CI, 1.1-5.1; P = 0.02) but not of positive remodeling. CONCLUSIONS EFV is greater in patients with CP, PCP, and NCP. In patients with NCP and PCP, EFV is significantly associated with severe coronary stenosis, high-risk plaque features, and low attenuation plaque.
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Affiliation(s)
- Ronak Rajani
- Department of Imaging, Cedars-Sinai Medical Center, Cedars-Sinai Heart Institute, 8700 Beverly Blvd., Los Angeles, CA 90048, USA
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