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Chow BJ, Galiwango P, Poulin A, Raggi P, Small G, Juneau D, Kazmi M, Ayach B, Beanlands RS, Sanfilippo AJ, Chow CM, Paterson DI, Chetrit M, Jassal DS, Connelly K, Larose E, Bishop H, Kass M, Anderson TJ, Haddad H, Mancini J, Doucet K, Daigle JS, Ahmadi A, Leipsic J, Lim SP, McRae A, Chou AY. Chest Pain Evaluation: Diagnostic Testing. CJC Open 2023; 5:891-903. [PMID: 38204849 PMCID: PMC10774086 DOI: 10.1016/j.cjco.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 01/12/2024] Open
Abstract
Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.
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Affiliation(s)
- Benjamin J.W. Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Galiwango
- Department of Medicine, Scarborough Health Network and Lakeridge Health, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Poulin
- Department of Medicine, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Paolo Raggi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gary Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniel Juneau
- Department of Radiology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Mustapha Kazmi
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Ayach
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Rob S. Beanlands
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Anthony J. Sanfilippo
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Chi-Ming Chow
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D. Ian Paterson
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Chetrit
- Department of Cardiovascular Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Davinder S. Jassal
- Department of Physiology and Pathophysiology, Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim Connelly
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Larose
- Department of Medicine, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Quebec, Canada
| | - Helen Bishop
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Malek Kass
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd J. Anderson
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Haissam Haddad
- Division of Cardiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - John Mancini
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katie Doucet
- Peterborough Regional Health Centre, Kawartha Cardiology Clinic, Peterborough, Ontario, Canada
| | - Jean-Sebastien Daigle
- Department of Internal Medicine, Dr Everett Chalmers Hospital, Fredericton, New Brunswick, Canada
| | - Amir Ahmadi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Leipsic
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Siok Ping Lim
- Mayfair Diagnostics, Saskatoon, Saskatchewan, Canada
| | - Andrew McRae
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Annie Y. Chou
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, St. Paul’s Hospital, Vancouver, British Columbia, Canada
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Kadoya Y, Naji K, Chow BJ, Small GR, Wells RG, Ruddy TD. REDUCING STUDY TIME FOR REST/STRESS 99MTC-TETROFOSMIN MYOCARDIAL PERFUSION IMAGING WITH MYOCARDIAL BLOOD FLOW MEASUREMENT USING CADMIUM-ZINC-TELLURIDE CAMERA IMAGING. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01892-2] [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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Fayyazifar N, Dwivedi G, Suter D, Ahderom S, Maiorana A, Clarkin O, Balamane S, Saha N, King B, Green MS, Golian M, Chow BJ. A novel convolutional neural network structure for differential diagnosis of wide QRS complex tachycardia. Biomed Signal Process Control 2023. [DOI: 10.1016/j.bspc.2022.104506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Taqueti VR, Shah AM, Everett BM, Pradhan AD, Piazza G, Bibbo C, Hainer J, Morgan V, Carolina do A. H. de Souza A, Skali H, Blankstein R, Dorbala S, Goldhaber SZ, Le May MR, Chow BJ, deKemp RA, Hage FG, Beanlands RS, Libby P, Glynn RJ, Solomon SD, Ridker PM, Di Carli MF. Coronary Flow Reserve, Inflammation, and Myocardial Strain: The CIRT-CFR Trial. JACC Basic Transl Sci 2023; 8:141-151. [PMID: 36908662 PMCID: PMC9998473 DOI: 10.1016/j.jacbts.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/17/2022] [Indexed: 12/24/2022]
Abstract
Inflammation is a key determinant of cardiovascular outcomes, but its role in heart failure is uncertain. In patients with cardiometabolic disease enrolled in the prospective, multicenter ancillary study of CIRT (Cardiovascular Inflammation Reduction Trial), CIRT-CFR (Coronary Flow Reserve to Assess Cardiovascular Inflammation), impaired coronary flow reserve was independently associated with increased inflammation and myocardial strain despite well-controlled lipid, glycemic, and hemodynamic profiles. Inflammation modified the relationship between CFR and myocardial strain, disrupting the association between cardiac blood flow and function. Future studies are needed to investigate whether an early inflammation-mediated reduction in CFR capturing microvascular ischemia may lead to heart failure in patients with cardiometabolic disease. (Cardiovascular Inflammation Reduction Trial [CIRT]; NCT01594333; Coronary Flow Reserve to Assess Cardiovascular Inflammation [CIRT-CFR]; NCT02786134).
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Key Words
- BMI, body mass index
- CAD, coronary artery disease
- CFR, coronary flow reserve
- CT, computed tomography
- GLS, global longitudinal strain
- HDL, high-density lipoprotein cholesterol
- HFpEF, heart failure with preserved ejection fraction
- IL, interleukin
- LDL, low-density lipoprotein cholesterol
- LDM, low-dose methotrexate
- LVEF, left ventricular ejection fraction
- MBF, myocardial blood flow
- MI, myocardial infarction
- NHLBI, National Heart, Lung, and Blood Institute
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- PET, positron emission tomography
- cardiometabolic disease
- cardiovascular trial coronary flow reserve
- coronary microvascular dysfunction
- heart failure
- hsCRP, high-sensitivity C-reactive protein
- hsTNT, high-sensitivity troponin T
- inflammation
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Affiliation(s)
- Viviany R. Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amil M. Shah
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendan M. Everett
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aruna D. Pradhan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria Morgan
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ana Carolina do A. H. de Souza
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michel R. Le May
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Benjamin J.W. Chow
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Robert A. deKemp
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Fadi G. Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Rob S. Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Peter Libby
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J. Glynn
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott D. Solomon
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Ridker
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Chow BJ, Chowdary P, Khurram MA, Mohamed IH. O061 A single-centre retrospective study in a large tertiary renal centre on the management of infected arteriovenous grafts. Br J Surg 2022. [DOI: 10.1093/bjs/znac242.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Introduction
Prosthetic arteriovenous grafts (AVGs) are often used as tertiary vascular access for haemodialysis in patients with exhausted autogenous options. AVGs are associated with an increased risk of infection which can lead to excess morbidity and life-threatening complications. Infected AVGs are challenging to manage, and the current evidence remains unclear on optimal strategy with arguments for conservative management, salvaging with revision or surgical excision (subtotal or total). This study sought to evaluate the management of infected AVGs by examining the clinical outcomes of patients with infected AVGs managed in our institution.
Methods
We conducted a single-centre retrospective study of all AVG infections managed (conservative management via antibiotics; graft revision; surgical excision) between June 2016 to May 2021. Primary outcome was mortality at 1 year. Secondary outcome was functional vascular access at 6 months and 1 year. Data were extracted from electronic patient records, radiology imaging and reporting.
Results
34 patients were included in our study (14.7% conservatively managed; 14.7% revision; 70.6% surgical excision) with a mean age of 60.4 ± 14.4 years (67.6% males). Average time from AVG placement to presentation was 11.8 months. 1 year mortality was 14.7%. Functional vascular access at 6 months in the three groups was 60%, 60% and 10% and 1-year functional vascular access was 60%, 75% and 42% respectively.
Conclusion
Surgically excised infected AVGs are associated with poor 6-month and 1-year vascular access outcomes. The findings suggest that conservative management and/or revision are more prudent given their higher probability of subsequent functional access.
Take-home message
Provision of a definite vascular access within the first year of graft infection is highly challenging. As such, conservative management and graft revision present as superior options to manage infected arteriovenous grafts.
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Affiliation(s)
- BJ Chow
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London
| | - P Chowdary
- Department of Renal and Transplantation, Royal London Hospital, Bart's Health NHS Trust
| | - MA Khurram
- Department of Renal and Transplantation, Royal London Hospital, Bart's Health NHS Trust
| | - IH Mohamed
- Department of Renal and Transplantation, Royal London Hospital, Bart's Health NHS Trust
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van Rosendael AR, van den Hoogen IJ, Lin FY, Gianni U, Lu Y, Andreini D, Al-Mallah MH, Cademartiri F, Chinnaiyan K, Chow BJ, Conte E, Cury RC, Feuchtner G, de Araújo Gonçalves P, Hadamitzky M, Kim YJ, Leipsic JA, Maffei E, Marques H, Plank F, Pontone G, Raff GL, Villines TC, Lee SE, Al’Aref SJ, Baskaran L, Cho I, Danad I, Gransar H, Budoff MJ, Samady H, Virmani R, Min JK, Narula J, Berman DS, Chang HJ, Shaw LJ, Bax JJ. Age related compositional plaque burden by CT in patients with future ACS. J Cardiovasc Comput Tomogr 2022; 16:491-497. [DOI: 10.1016/j.jcct.2022.05.005] [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] [Received: 02/18/2022] [Revised: 05/15/2022] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
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Al’Aref SJ, Singh G, Choi JW, Xu Z, Maliakal G, van Rosendael AR, Lee BC, Fatima Z, Andreini D, Bax JJ, Cademartiri F, Chinnaiyan K, Chow BJ, Conte E, Cury RC, Feuchtner G, Hadamitzky M, Kim YJ, Lee SE, Leipsic JA, Maffei E, Marques H, Plank F, Pontone G, Raff GL, Villines TC, Weirich HG, Cho I, Danad I, Han D, Heo R, Lee JH, Rizvi A, Stuijfzand WJ, Gransar H, Lu Y, Sung JM, Park HB, Berman DS, Budoff MJ, Samady H, Stone PH, Virmani R, Narula J, Chang HJ, Lin FY, Baskaran L, Shaw LJ, Min JK. A Boosted Ensemble Algorithm for Determination of Plaque Stability in High-Risk Patients on Coronary CTA. JACC Cardiovasc Imaging 2020; 13:2162-2173. [DOI: 10.1016/j.jcmg.2020.03.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 12/17/2022]
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Small GR, Erthal F, Alenazy A, Yam Y, Edwards M, Crean A, Beanlands RS, Ruddy TD, Chow BJ. Comparison of coronary CT angiography versus functional imaging for CABG patients: A resource utilization analysis. Int J Cardiol Heart Vasc 2020; 27:100494. [PMID: 32181322 PMCID: PMC7063132 DOI: 10.1016/j.ijcha.2020.100494] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 11/26/2022]
Abstract
AIMS The impact of anatomical versus functional testing in patients with prior coronary artery bypass surgery (CABG) is poorly defined. We therefore sought to determine the rates of downstream investigations and the attendant healthcare costs in CABG patients undergoing CCTA versus SPECT. METHODS AND RESULTS 2754 consecutive CABG patients were imaged by SPECT (2163) or CCTA (591). 425 patients (15.4%) underwent downstream testing which was more common in those imaged with CCTA versus SPECT (23.18% vs 13.31% respectively, p < 0.01). When a propensity score adjustment was made for differences in baseline characteristics, the findings in downstream testing persisted (p < 0.01). When patients who subsequently underwent repeat revascularization (arguably the highest risk patients) were removed from the analysis, downstream testing remained more frequent in CCTA (12.7%) versus SPECT imaged patients (8.8%) (p = 0.01). Costs of downstream tests per patient were two-fold greater in the CCTA group in comparison to the SPECT group ($366.79 ± 29.59 vs $167.35 ± 10.12 respectively, p < 0.01). Conversely, total costs which included the index costs were less in the CCTA group, $764.66 ± 29.59 versus $1396.73 ± 1012 for the SPECT cohort, p < 0.0001). CONCLUSIONS Index imaging with SPECT versus CCTA in CABG patients was associated with fewer downstream tests, less ICA, less repeat revascularization but greater expense. Cost however is only part of the decision making process that determines an optimal index test. Until CCTA demonstrates improved risk stratification over SPECT in CABG patients it is likely SPECT will remain the preferred first imaging test.
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Affiliation(s)
- Gary R. Small
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Fernanda Erthal
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Ali Alenazy
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Yeung Yam
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Michael Edwards
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Andrew Crean
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Rob S. Beanlands
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Terrence D. Ruddy
- University of Ottawa Heart Institute, Division of Cardiology, Canada
| | - Benjamin J.W. Chow
- University of Ottawa Heart Institute, Division of Cardiology, Canada
- University of Ottawa, Department of Radiology, Canada
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Chow BJ, Alenazy A, Small G, Crean A, Yam Y, Beanlands RS, Clarkin O, Froeschl M, Ruddy TD, Hossain A. Competency-Based Medical Education. JACC Cardiovasc Imaging 2019; 12:2505-2513. [DOI: 10.1016/j.jcmg.2019.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/19/2019] [Accepted: 09/30/2019] [Indexed: 01/01/2023]
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Walpot J, Inácio JR, Massalha S, El mais H, Hossain A, Shiau J, Small GR, Crean AM, Yam Y, Rybicki F, Chow BJ. Early LV remodelling patterns in overweight and obesity: Feasibility of cardiac CT to detect early geometric left ventricular changes. Obes Res Clin Pract 2019; 13:478-485. [DOI: 10.1016/j.orcp.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/21/2019] [Accepted: 07/26/2019] [Indexed: 02/06/2023]
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Alqahtani AM, Boczar KE, Kansal V, Chan K, Dwivedi G, Chow BJ. Quantifying Aortic Valve Calcification using Coronary Computed Tomography Angiography. J Cardiovasc Comput Tomogr 2017; 11:99-104. [DOI: 10.1016/j.jcct.2017.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 01/18/2017] [Accepted: 01/25/2017] [Indexed: 01/07/2023]
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Juneau D, Erthal F, Clarkin O, Alzahrani A, Alenazy A, Hossain A, Inacio JR, Dwivedi G, Dick AJ, Rybicki FJ, Chow BJ. Mid-diastolic left ventricular volume and mass: Normal values for coronary computed tomography angiography. J Cardiovasc Comput Tomogr 2017; 11:135-140. [DOI: 10.1016/j.jcct.2017.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 01/24/2017] [Accepted: 01/29/2017] [Indexed: 11/16/2022]
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Deseive S, Shaw LJ, Min JK, Achenbach S, Andreini D, Al-Mallah MH, Berman DS, Budoff MJ, Callister TQ, Cademartiri F, Chang HJ, Chinnaiyan K, Chow BJ, Cury RC, DeLago A, Dunning AM, Feuchtner G, Kaufmann PA, Kim YJ, Leipsic J, Marques H, Maffei E, Pontone G, Raff G, Rubinshtein R, Villines TC, Hausleiter J, Hadamitzky M. Improved 5-year prediction of all-cause mortality by coronary CT angiography applying the CONFIRM score. Eur Heart J Cardiovasc Imaging 2017; 18:286-293. [PMID: 28363203 PMCID: PMC5837486 DOI: 10.1093/ehjci/jew195] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 05/12/2016] [Accepted: 08/10/2016] [Indexed: 11/13/2022] Open
Abstract
AIMS To investigate the long-term performance of the CONFIRM score for prediction of all-cause mortality in a large patient cohort undergoing coronary computed tomography angiography (CCTA). METHODS AND RESULTS Patients with a 5-year follow-up from the international multicentre CONFIRM registry were included. The primary endpoint was all-cause mortality. The predictive value of the CONFIRM score over clinical risk scores (Morise, Framingham, and NCEP ATP III score) was studied in the entire patient population as well as in subgroups. Improvement in risk prediction and patient reclassification were assessed using categorical net reclassification index (NRI) and integrated discrimination improvement (IDI). During a median follow-up period of 5.3 years, 982 (6.5%) of 15 219 patients died. The CONFIRM score outperformed the prognostic value of the studied three clinical risk scores (c-indices: CONFIRM score 0.696, NCEP ATP III score 0.675, Framingham score 0.610, Morise score 0.606; c-index for improvement CONFIRM score vs. NCEP ATP III score 0.650, P < 0.0001). Application of the CONFIRM score allowed reclassification of 34% of patients when compared with the NCEP ATP III score, which was the best clinical risk score. Reclassification was significant as revealed by categorical NRI (0.06 with 95% CI 0.02 and 0.10, P = 0.005) and IDI (0.013 with 95% CI 0.01 and 0.015, P < 0.001). Subgroup analysis revealed a comparable performance in a variety of patient subgroups. CONCLUSIONS The CONFIRM score permits a significantly improved prediction of mortality over clinical risk scores for >5 years after CCTA. These findings are consistent in a large variety of patient subgroups.
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Affiliation(s)
- Simon Deseive
- Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Leslee J. Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - James K. Min
- Department of Radiology, New York Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA
| | | | - Daniele Andreini
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico, Monzino, IRCCS Milan, Milano, Italy
| | - Mouaz H. Al-Mallah
- Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA
| | - Daniel S. Berman
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew J. Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA
| | | | - Filippo Cademartiri
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | | | - Benjamin J.W. Chow
- Department of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada
| | | | | | | | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada
| | | | - Erica Maffei
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gianluca Pontone
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico, Monzino, IRCCS Milan, Milano, Italy
| | | | - Ronin Rubinshtein
- Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel, Institute of Technology, Haifa, Israel
| | - Todd C. Villines
- Department of Medicine, Walter Reed Medical Center, Washington, DC, USA
| | - Jörg Hausleiter
- Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Hadamitzky
- Division of Radiology, Deutsches Herzzentrum Muenchen, Lazarettstr. 36, Munich 80636, Germany
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Dowsley TF, Chepelev L, McArdle B, Alam M, Dwivedi G, Chow BJ. Improved diagnostic accuracy when combining computed tomography angiography and corrected coronary opacification in patients with coronary stents. Acta Cardiol 2017; 72:53-60. [PMID: 28597738 DOI: 10.1080/00015385.2017.1281525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 10/19/2022]
Abstract
Background The accuracy of coronary computed tomography angiography (CCTA) is sub-optimal in patients with coronary stents. Methods that can increase its diagnostic accuracy are desirable. Objective A proof-of-concept study was undertaken to determine if corrected coronary opacification (CCO) differences can improve the accuracy of CCTA in stented coronary arteries. Methods PCI patients who underwent both CCTA and invasive coronary angiography (ICA) within 3 months were analyzed. Coronary luminal attenuation values (normalized to the aorta) were measured proximally and distally to coronary stents. CCO differences were evaluated for ability to predict (i) stenosis on invasive angiography, (ii) abnormal resting coronary flow as measured by the corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC), and (iii) the combination of abnormal resting flow and significant stenosis on invasive angiography. Results Twenty-nine stented coronary arteries (n = 25, mean age =61.4 years, men =80.0%) were assessed. In stented coronary vessels, CCO identified stenosis (≥ 70%) with an area under the curve of 0.767 (P = 0.021). CCO predicted abnormal resting coronary flow with high accuracy (AUC =0.867, P = 0.002). Combined CCTA/CCO identified both abnormal cTFC and stenosis ≥70% on ICA (functionally significant stenosis) with diagnostic accuracy of 92.3%. In contrast, CCTA visual assessment alone had lower diagnostic accuracy of 66.7% for identifying functionally significant stenosis. Conclusion CCO differences are predictive of abnormal resting flow and consequently, in-stent restenosis. Incorporation of this technique may improve the specificity of CCTA in PCI patients.
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Affiliation(s)
- Taylor F. Dowsley
- University of Ottawa Heart Institute, Department of Medicine (Cardiology), Canada
| | - Leonid Chepelev
- University of Ottawa Heart Institute, Department of Medicine (Cardiology), Canada
| | - Brian McArdle
- University of Ottawa Heart Institute, Department of Medicine (Cardiology), Canada
| | - Mohammed Alam
- University of Ottawa Heart Institute, Department of Medicine (Cardiology), Canada
| | - Girish Dwivedi
- University of Ottawa Heart Institute, Department of Medicine (Cardiology), Canada
| | - Benjamin J.W. Chow
- University of Ottawa Heart Institute, Department of Medicine (Cardiology), Canada
- University of Ottawa, Canada Department of Radiology, Canada
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Ayoub C, Yam Y, Chen L, Arasaratnam P, Chow CK, Hillis GS, Kritharides L, Chow BJ. The Prognostic Value of Percentage Total Plaque Score Adjusted to Age. Angiology 2016; 67:916-926. [DOI: 10.1177/0003319716633354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Total plaque score (TPS) on coronary computed tomography angiography (CCTA) has been validated as a surrogate measure of coronary artery disease (CAD) burden and is prognostic. We propose a novel measure, percentage TPS adjusted to age (%TPS/age), that may reflect vascular age and potentially more rapidly progressive atherosclerosis and evaluate its potential prognostic value. Methods: %TPS/age was calculated for consecutive patients prospectively enrolled into our institutional CCTA registry and evaluated for primary composite outcome of cardiac death, nonfatal myocardial infarction, and late revascularization. Results: Of 1896 patients identified (mean age 57.7 ± 11.4 years, 50.1% male, median follow-up 18.6 months [interquartile range: 15.3, 32.4]), 552 (29%) had %TPS/age = 0 (no atherosclerosis), with 1 (0.2%) primary outcome observed (annual event rate [AER] = 0.1%). Two events (0.4%, AER = 0.3%) were observed in %TPS/age < 0.314 category, 22 (5.0%, AER = 2.2%) in %TPS/age 0.314 to 0.699 category, and 54 (12.0%, AER = 5.7%) in %TPS/age ≥ 0.700 category. After adjusting for clinical predictors and obstructive CAD, higher %TPS/age category was associated with hazard ratio 1.95 (1.31-2.88, P < .001) for primary outcome on multivariable analysis, Harrell-C-Statistic 0.87 (confidence interval 95%: 0.84-0.90), and net reclassification improvement of 0.71 ( P < .001). Conclusion: %TPS/Age has incremental prognostic value to traditional risk factors and CCTA measures of CAD and improves evaluation of burden of coronary atherosclerosis and clinical risk.
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Affiliation(s)
- Chadi Ayoub
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, ON, Canada
- University of Sydney, New South Wales, Australia
| | - Yeung Yam
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, ON, Canada
| | - Li Chen
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, ON, Canada
| | - Punitha Arasaratnam
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, ON, Canada
| | | | - Graham S. Hillis
- University of Sydney, New South Wales, Australia
- Department of Cardiology, Royal Perth Hospital, University of Western Australia
| | - Leonard Kritharides
- University of Sydney, New South Wales, Australia
- Department of Cardiology, Concord Hospital, Sydney Local Health District, New South Wales, Australia
| | - Benjamin J.W. Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, ON, Canada
- Department of Radiology, University of Ottawa, ON, Canada
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Yang Y, Chen L, Yam Y, Achenbach S, Al-Mallah M, Berman DS, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Cheng VY, Chinnaiyan K, Cury R, Delago A, Dunning A, Feuchtner G, Hadamitzky M, Hausleiter J, Karlsberg RP, Kaufmann PA, Kim YJ, Leipsic J, LaBounty T, Lin F, Maffei E, Raff GL, Shaw LJ, Villines TC, Min JK, Chow BJ. A Clinical Model to Identify Patients With High-Risk Coronary Artery Disease. JACC Cardiovasc Imaging 2015; 8:427-434. [DOI: 10.1016/j.jcmg.2014.11.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/10/2014] [Indexed: 10/23/2022]
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Sadek MM, Chow BJ. The Risks of Computed Tomography Go Beyond Radiation. Can J Cardiol 2014; 30:697.e5-6. [DOI: 10.1016/j.cjca.2013.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 03/10/2013] [Accepted: 04/03/2013] [Indexed: 11/30/2022] Open
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Dwivedi G, Al-Shehri H, deKemp RA, Ali I, Alghamdi AA, Klein R, Scullion A, Ruddy TD, Beanlands RS, Chow BJ. Scar imaging using multislice computed tomography versus metabolic imaging by F-18 FDG positron emission tomography: A pilot study. Int J Cardiol 2013; 168:739-45. [DOI: 10.1016/j.ijcard.2012.09.218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 09/24/2012] [Accepted: 09/29/2012] [Indexed: 11/26/2022]
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Al-Mohaissen MA, Kazmi MH, Chan KL, Chow BJ. Validation of Two-Dimensional Methods for Left Atrial Volume Measurement: A Comparison of Echocardiography with Cardiac Computed Tomography. Echocardiography 2013; 30:1135-42. [DOI: 10.1111/echo.12253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Maha A. Al-Mohaissen
- Department of Medicine (Cardiology); University of Ottawa Heart Institute; Ottawa Canada
| | - Mustapha H. Kazmi
- Department of Medicine (Cardiology); University of Ottawa Heart Institute; Ottawa Canada
| | - Kwan Leung Chan
- Department of Medicine (Cardiology); University of Ottawa Heart Institute; Ottawa Canada
| | - Benjamin J.W. Chow
- Department of Medicine (Cardiology); University of Ottawa Heart Institute; Ottawa Canada
- Department of Radiology; University of Ottawa; Ottawa Canada
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Otaki Y, Gransar H, Berman DS, Cheng VY, Dey D, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan K, Chow BJ, Delago A, Hadamitzky M, Hausleiter J, Kaufmann P, Maffei E, Raff G, Shaw LJ, Villines TC, Dunning A, Min JK. Impact of family history of coronary artery disease in young individuals (from the CONFIRM registry). Am J Cardiol 2013; 111:1081-6. [PMID: 23411105 DOI: 10.1016/j.amjcard.2012.12.042] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 02/08/2023]
Abstract
Although family history (FH) of coronary artery disease (CAD) is considered a risk factor for future cardiovascular events, the prevalence, extent, severity, and prognosis of young patients with FH of CAD have been inadequately studied. From 27,125 consecutive patients who underwent coronary computed tomographic angiography, 6,308 young patients (men aged <55 years and women aged <65 years) without known CAD were identified. Obstructive CAD was defined as >50% stenosis in a coronary artery >2 mm diameter. Risk-adjusted logistic regression, Kaplan-Meier, and Cox proportional-hazards models were used to compare patients with and without FH of CAD. Compared with subjects without FH of CAD, those with FH of CAD (FH+) had higher prevalences of any CAD (40% vs 30%, p <0.001) and obstructive CAD (11% vs 7%, p <0.001), with multivariate odds of FH+ increasing the likelihood of obstructive CAD by 71% (p <0.001). After a mean follow-up period of 2 ± 1 years (42 myocardial infarctions and 39 all-cause deaths), FH+ patients experienced higher annual rates of myocardial infarction (0.5% vs 0.2%, log-rank p = 0.001), with a positive FH the strongest predictor of myocardial infarction (hazard ratio 2.6, 95% confidence interval 1.4 to 4.8, p = 0.002). In conclusion, young FH+ patients have higher presence, extent, and severity of CAD, which are associated with increased risk for myocardial infarction. Compared with other clinical CAD risk factors, positive FH in young patients is the strongest clinical predictor of future unheralded myocardial infarction.
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Tardif JC, Spence JD, Heinonen TM, Moody A, Pressacco J, Frayne R, L'Allier P, Chow BJ, Friedrich M, Black SE, Fenster A, Rutt B, Beanlands R. Atherosclerosis Imaging and the Canadian Atherosclerosis Imaging Network. Can J Cardiol 2013; 29:297-303. [DOI: 10.1016/j.cjca.2012.09.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022] Open
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23
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Nakanishi R, Gransar H, Berman DS, Cheng V, Dey D, LaBounty T, Lin F, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister T, Chinnaiyan K, Chow BJ, Delago A, Hadamitzky M, Hausleiter J, Raff G, Villines T, Shaw LJ, Dunning A, Min JK. DOES NONCALCIFIED PLAQUE IMPROVE THE DIAGNOSTIC AND PROGNOSTIC UTILITY OF CORONARY CT ANGIOGRAPHY? A STUDY OF PROPENSITY-MATCHED INDIVIDUALS WITH SIMILAR CORONARY CALCIUM SCORES FROM THE PROSPECTIVE MULTICENTER INTERNATIONAL CONFIRM REGISTRY. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)61370-9] [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: 11/27/2022]
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Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Cheng V, Chinnaiyan K, Chow BJ, Delago A, Hadamitzky M, Hausleiter J, Kaufmann P, Maffei E, Raff G, Shaw LJ, Villines T, Berman DS. Reply. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2011.10.885] [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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Hachamovitch R, Nutter B, Hlatky MA, Shaw LJ, Ridner ML, Dorbala S, Beanlands RS, Chow BJ, Branscomb E, Chareonthaitawee P, Weigold WG, Voros S, Abbara S, Yasuda T, Jacobs JE, Lesser J, Berman DS, Thomson LE, Raman S, Heller GV, Schussheim A, Brunken R, Williams KA, Farkas S, Delbeke D, Schoepf UJ, Reichek N, Rabinowitz S, Sigman SR, Patterson R, Corn CR, White R, Kazerooni E, Corbett J, Bokhari S, Machac J, Guarneri E, Borges-Neto S, Millstine JW, Caldwell J, Arrighi J, Hoffmann U, Budoff M, Lima J, Johnson JR, Johnson B, Gaber M, Williams JA, Foster C, Hainer J, Di Carli MF. Patient Management After Noninvasive Cardiac Imaging. J Am Coll Cardiol 2012; 59:462-74. [DOI: 10.1016/j.jacc.2011.09.066] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/05/2011] [Accepted: 09/15/2011] [Indexed: 10/14/2022]
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Small GR, Yam Y, Chen L, Ahmed O, Al-Mallah M, Berman DS, Cheng VY, Chinnaiyan K, Raff G, Villines TC, Achenbach S, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Delago A, Dunning A, Hadamitzky M, Hausleiter J, Kaufmann P, Lin F, Maffei E, Min JK, Shaw LJ, Chow BJ. Prognostic Assessment of Coronary Artery Bypass Patients With 64-Slice Computed Tomography Angiography. J Am Coll Cardiol 2011; 58:2389-95. [DOI: 10.1016/j.jacc.2011.08.047] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/13/2011] [Accepted: 08/09/2011] [Indexed: 11/27/2022]
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Chow BJ, Small G, Yam Y, Chen L, Achenbach S, Al-Mallah M, Berman DS, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Cheng V, Chinnaiyan KM, Delago A, Dunning A, Hadamitzky M, Hausleiter J, Kaufmann P, Lin F, Maffei E, Raff GL, Shaw LJ, Villines TC, Min JK. Incremental Prognostic Value of Cardiac Computed Tomography in Coronary Artery Disease Using CONFIRM. Circ Cardiovasc Imaging 2011; 4:463-72. [DOI: 10.1161/circimaging.111.964155] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background—
Large multicenter studies validating the prognostic value of coronary computed tomographic angiography (CCTA) and left ventricular ejection fraction (LVEF) are lacking. We sought to confirm the independent and incremental prognostic value of coronary artery disease (CAD) severity measured using 64-slice CCTA over LVEF and clinical variables.
Methods and Results—
A large international multicenter registry (CONFIRM Registry) was queried, and CCTA patients with LVEF data on CCTA were screened. Patients with a history of myocardial infarction, coronary revascularization, or cardiac transplantation were excluded. The National Cholesterol Education Program-Adult Treatment Panel III risk was calculated for each patient, and CCTA was evaluated for CAD severity (normal, nonobstructive, non–high-risk, or high-risk CAD) and LVEF <50%. Patients were followed for an end point of all-cause mortality; 27 125 patients underwent CCTA at 12 participating centers, with a total of 14 064 patients meeting the analysis criteria. Follow-up was available for 13 966 (99.3%) patients (mean follow-up of 22.5 months; 95% confidence interval, 22.3 to 22.7 months). All-cause mortality (271 deaths) occurred in 0.65% of patients without coronary atherosclerosis, 1.99% of patients with nonobstructive CAD, 2.90% of patients with non–high-risk CAD, and 4.95% for patients with high-risk CAD. Multivariable analysis confirmed that LVEF <50% (hazard ratio, 2.74; 95% confidence interval, 2.12 to 3.51) and CAD severity (hazard ratio,1.58; 95% confidence interval, 1.42 to 1.76) were predictors of all-cause mortality, and CAD severity had incremental value over LVEF and clinical variables.
Conclusions—
Our results demonstrate that CCTA measures of CAD severity and LVEF have independent prognostic value. Incorporation of CAD severity provides incremental value for predicting all-cause death over routine clinical predictors and LVEF in patients with suspected obstructive CAD.
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Affiliation(s)
- Benjamin J.W. Chow
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Gary Small
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Yeung Yam
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Li Chen
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Stephan Achenbach
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Mouaz Al-Mallah
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Daniel S. Berman
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Matthew J. Budoff
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Filippo Cademartiri
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Tracy Q. Callister
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Hyuk-Jae Chang
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Victor Cheng
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Kavitha M. Chinnaiyan
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Augustin Delago
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Allison Dunning
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Martin Hadamitzky
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Jörg Hausleiter
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Philipp Kaufmann
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Fay Lin
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Erica Maffei
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Gilbert L. Raff
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Leslee J. Shaw
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - Todd C. Villines
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
| | - James K. Min
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C.); the Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); the Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI (M.A.-M.); the Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.C.); the Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA (M.J.B.); the Department of Radiology,
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Galiwango P, Chow BJ. Cardiac Computed Tomography and Risks of Radiation Exposure: How Low Can We Go? Can J Cardiol 2011; 27:536-7. [DOI: 10.1016/j.cjca.2010.12.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 10/15/2010] [Indexed: 10/17/2022] Open
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Ziadi MC, deKemp RA, Williams KA, Guo A, Chow BJ, Renaud JM, Ruddy TD, Sarveswaran N, Tee RE, Beanlands RS. Impaired Myocardial Flow Reserve on Rubidium-82 Positron Emission Tomography Imaging Predicts Adverse Outcomes in Patients Assessed for Myocardial Ischemia. J Am Coll Cardiol 2011; 58:740-8. [DOI: 10.1016/j.jacc.2011.01.065] [Citation(s) in RCA: 331] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 01/25/2011] [Accepted: 01/31/2011] [Indexed: 10/17/2022]
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Chow BJ, Ahmed O, Small G, Alghamdi AA, Yam Y, Chen L, Wells GA. Prognostic Value of CT Angiography in Coronary Bypass Patients. JACC Cardiovasc Imaging 2011; 4:496-502. [DOI: 10.1016/j.jcmg.2011.01.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 01/14/2011] [Accepted: 01/18/2011] [Indexed: 10/18/2022]
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Cheng V, Berman DS, Dunning AL, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan KM, Chow BJ, Delago AJ, Hadamitzky M, Hausleiter J, Kaufmann P, Lin FY, Nasir K, Raff G, Shaw LJ, Villines TC, Min JK. CIGARETTE SMOKING, PROXIMAL CORONARY ARTERIAL PLAQUE COMPOSITION, AN RISK OF MYOCARDIAL INFARCTION AND DEATH: A STUDY OF NONDIABETIC MEN AND WOMEN IN THE MULTINATIONAL CONFIRM REGISTRY (CORONARY CT ANGIOGRAPHY EVALUATION FOR CLINICAL OUTCOMES: AN INTERNATIONAL MULTICENTER REGISTRY). J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60641-4] [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: 10/18/2022]
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Lin F, Chinnaiyan K, Dunning AM, Shaw LJ, Achenbach S, Al-Mallah M, Berman DS, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chow BJ, Delago AJ, Hausleiter J, Hadamitzky M, Kaufmann P, Raff GL, Villines T, Min JK. GENDER DIFFERENCES IN ALL-CAUSE DEATH BY EXTENT AND SEVERITY OF CORONARY ARTERY DISEASE BY CARDIAC COMPUTED TOMOGRAPHIC ANGIOGRAPHY: A MATCHED ANALYSIS OF THE CONFIRM REGISTRY. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60773-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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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Chang HJ, Cho I, Dunning A, Delago A, Chow BJ, Berman D, Cademartiri F, Raff G, Hausleiter J, Shaw LJ, Hadamitzky M, Budoff M, Al-Mallah M, Kaufmann P, Achenbach S, Villines T, Callister T, Min JK. PROGNOSTIC VALUE OF CORONARY CT ANGIOGRAPHY IN ASYMPTOMATIC POPULATION: COMPARISONS WITH CONVENTIONAL RISK STRATIFICATION ALGORITHM AND CALCIUM SCORING. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60642-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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LaBounty T, Gomez M, Dunning AM, Lin FY, Delago A, Chow BJ, Berman D, Cadermartiri F, Raff G, Chang HJ, Hausleiter J, Shaw LJ, Hadamitzky M, Budoff M, Al-Mallah M, Kaufmann P, Achenbach S, Villines T, Callister T, Min JK. INCREASED BODY MASS INDEX IS ASSOCIATED WITH GREATER PREVALENCE, EXTENT AND SEVERITY OF CORONARY ARTERY DISEASE. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60728-6] [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: 11/16/2022]
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Chow BJ, Ahmed O, Small G, Alghamdi AA, Yam Y, Chen L, Wells GA. PROGNOSTIC VALUE OF 64-SLICE CARDIAC CT IN CORONARY BYPASS PATIENTS: GRAFT PATENCY AND LEFT VENTRICULAR EJECTION FRACTION. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60777-8] [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: 11/25/2022]
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Abunassar JG, Yam Y, Chen L, D'Mello N, Chow BJ. Usefulness of the Agatston score = 0 to exclude ischemic cardiomyopathy in patients with heart failure. Am J Cardiol 2011; 107:428-32. [PMID: 21257010 DOI: 10.1016/j.amjcard.2010.09.040] [Citation(s) in RCA: 19] [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: 06/29/2010] [Revised: 09/22/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
Abstract
Quantification of coronary artery calcium has prognostic value and is commonly used in asymptomatic patients. Routine clinical use of coronary artery calcium in other populations remains uncertain. We sought to understand the potential application of the Agatston score in patients with heart failure (HF). For this purpose, 3 populations were identified: (1) patients with an Agatston score equal to 0, (2) patients with high-risk coronary artery disease (CAD) defined as 3-vessel, left main, or 2-vessel disease involving the proximal left anterior descending coronary artery, and (3) patients with HF symptoms and left ventricular (LV) ejection fraction <50%. Excluding patients with HF or LV dysfunction, 738 patients (mean age 52 ± 10 years, 43% men) had an Agatston score equal to 0. Of these, 18 (2%) had obstructive CAD (diameter stenosis ≥50%), 8 (1%) had diameter stenoses ≥70%, and none had high-risk CAD. The 74 patients with high-risk CAD without LV dysfunction had high Agatston scores (mean 895 ± 734, median 716, range 50 to 3,210). In total 153 patients with a history of HF and abnormal ejection fraction were identified. All 13 patients with ischemic cardiomyopathy had Agatston scores >0, whereas 46 of 140 patients (30.1%) with nonischemic causes had an Agatston score equal to 0. An Agatston score equal to 0 identified nonischemic causes with a specificity of 100% (confidence interval 90 to 100) and positive predictive value of 100% (confidence interval 90 to 100). Agatston score equal to 0 had incremental value to pretest probability for CAD. In conclusion, an Agatston score equal to 0 confers a very low likelihood of obstructive CAD, appears to rule out high-risk CAD, and thus may be used to rule out ischemic cardiomyopathy in patients with HF.
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Chow BJ, Joseph P, Yam Y, Kass M, Chen L, Beanlands RS, Ruddy TD. Usefulness of computed tomographic coronary angiography in patients with acute chest pain with and without high-risk features. Am J Cardiol 2010; 106:463-9. [PMID: 20691302 DOI: 10.1016/j.amjcard.2010.03.058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 03/25/2010] [Accepted: 03/25/2010] [Indexed: 10/19/2022]
Abstract
The accuracy of 64-slice computed tomographic coronary angiography (CTA) and its ability to direct revascularization in patients with acute chest pain syndrome (ACPS) was investigated. A total of 107 patients with ACPS presenting to the emergency department and referred to cardiology were prospectively enrolled and underwent CTA. From the clinical features, the patients were categorized as having high-risk acute coronary syndrome features or no high-risk features. At the treating physician's discretion, the patients underwent risk stratification with either invasive coronary angiography (ICA) or technetium-99m single photon emission computed tomography. All tests were interpreted by experts unaware of the clinical information. All 52 patients with high-risk acute coronary syndrome features underwent ICA. Of the 55 patients with no high-risk features, 36 underwent single photon emission computed tomography and 19 underwent ICA. The patients were followed up until a decision regarding revascularization was made. Compared with ICA, the operating characteristics of CTA (per-patient analysis) were excellent, with a sensitivity of 98% (95% confidence interval [CI] 87% to 100%), specificity of 100% (95% CI 85% to 100%), positive predictive value of 100% (95% CI 90% to 100%), and negative predictive value of 97% (95% CI 80% to 100%). The agreement between CTA and routine testing (single photon emission computed tomography or ICA) was very good (kappa = 0.94). CTA correctly identified 40 patients (100%) who underwent revascularization and 61 (91.0%) who were treated medically (kappa = 0.88, 95% CI 0.79 to 0.97). In conclusion, CTA might represent a single modality that could be used to triage a wide spectrum of patients with ACPS and could have the potential to rule out coronary disease and identify those who might require revascularization.
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Chow BJ, Galiwango PJ, Law A, D’Mello N. Reply. J Am Coll Cardiol 2010. [DOI: 10.1016/j.jacc.2009.10.091] [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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Ruel M, Dickie S, Chow BJ, Labinaz M. Interventional Valve Surgery: Building a Team and Working Together. Semin Thorac Cardiovasc Surg 2010; 22:145-9. [DOI: 10.1053/j.semtcvs.2010.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2010] [Indexed: 11/11/2022]
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Chow BJ, Yam Y, Wells GA, Ruddy T. RATES OF INVASIVE CORONARY ANGIOGRAPHY, REVASCULARIZATION AND PATIENT OUTCOMES AFTER COMPUTED TOMOGRAPHIC CORONARY ANGIOGRAPHY. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60690-0] [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: 11/28/2022]
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Chow BJ, Abraham A, Wells GA, Chen L, Ruddy TD, Yam Y, Govas N, Galbraith PD, Dennie C, Beanlands RS. Diagnostic Accuracy and Impact of Computed Tomographic Coronary Angiography on Utilization of Invasive Coronary Angiography. Circ Cardiovasc Imaging 2009; 2:16-23. [DOI: 10.1161/circimaging.108.792572] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Computed tomographic coronary angiography (CTA), given its high negative predictive value, is a potential gatekeeper for invasive coronary angiography (ICA). Before CTA can be further accepted into clinical practice, its impact on healthcare resources needs to be better understood. We sought to determine the clinical impact of CTA on ICA referrals, CTA accuracy, and normalcy rate.
Methods and Results—
To determine the impact of CTA, consecutive patients (n=7017) undergoing ICA before and after implementing a dedicated cardiac CT program were reviewed and compared with 3 other centers (n=11 508). To determine CTA accuracy, we evaluated consecutive CTA patients who underwent ICA. For normalcy rate, we identified patients with a low pretest probability for obstructive coronary artery disease. With the implementation of a cardiac CT program, the frequency of normal ICA decreased from 31.5% (1114 of 3538 patients) to 26.8% (932 of 3479 patients) (
P
<0.001). These findings were significantly different (
P
=0.003) from the 3 centers, in which normal ICAs were unchanged (30.0% [1870 of 6224 patients] to 31.0% [1642 of 5284 patients]). CTA had excellent per-patient sensitivity (99% [CI, 95% to 100%]), positive predictive value (92% [CI, 86% to 96%]) and negative predictive value (95% [CI, 72% to 100%]). Because of referral bias, specificity (64% [CI, 44% to 81%]) was low; however, the normalcy rate of CTA was 94% (CI, 90% to 97%). After adjusting for referral bias, the adjusted sensitivity was 90% (CI, 89% to 91%), and the adjusted specificity was 95% (CI, 94% to 96%), with positive and negative predictive values of 92% (CI, 91% to 93%) and 93% (CI, 92% to 94%), respectively.
Conclusion—
The clinical implementation of CTA appears to positively impact ICA by reducing the frequency of normal ICA. The operating characteristics of CTA support its potential role as a tool useful in ruling out obstructive coronary artery disease.
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Affiliation(s)
- Benjamin J.W. Chow
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Arun Abraham
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - George A. Wells
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Li Chen
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Terrence D. Ruddy
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Yeung Yam
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Nayia Govas
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Phoebe Diane Galbraith
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Carole Dennie
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
| | - Rob S. Beanlands
- From the Department of Medicine (Cardiology), University of Ottawa Heart Institute (B.J.W.C., A.A., G.A.W., L.C., T.D.R., Y.Y., N.G., R.S.B.), Ottawa, Ontario, Canada; Department of Radiology, Ottawa Hospital (B.J.W.C., T.D.R., C.D., R.S.B.), Ottawa, Ontario, Canada; and Department of Cardiac Sciences, University of Calgary (P.D.G.), Calgary, Alberta, Canada
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Abidov A, Hachamovitch R, Friedman JD, Hayes SW, Kang X, Cohen I, Germano G, Berman DS, Kjaer A, Cortsen A, Federspiel M, Hesse B, Holm S, O’Connor M, Dhalla AK, Wong MY, Wang WQ, Belardinelli L, Therapeutics CV, Epps A, Dave S, Brewer K, Chiaramida S, Gordon L, Hendrix GH, Feng B, Pretorius PH, Bruyant PP, Boening G, Beach RD, Gifford HC, King MA, Fessler JA, Hsu BL, Case JA, Gegen LL, Hertenstein GK, Cullom SJ, Bateman TM, Akincioglu C, Abidov A, Nishina H, Kavanagh P, Kang X, Aboul-Enein F, Yang L, Hayes S, Friedman J, Berman D, Germano G, Santana CA, Rivero A, Folks RD, Grossman GB, Cooke CD, Hunsche A, Faber TL, Halkar R, Garcia EV, Hansen CL, Silver S, Kaplan A, Rasalingam R, Awar M, Shirato S, Reist K, Htay T, Mehta D, Cho JH, Heo J, Dubovsky E, Calnon DA, Grewal KS, George PB, Richards DR, Hsi DH, Singh N, Meszaros Z, Thomas JL, Reyes E, Loong CY, Latus K, Anagnostopoulos C, Underwood SR, Kostacos EJ, Araujo LI, Kostacos EJ, Araujo LI, Lewin HC, Hyun MC, DePuey EG, Tanaka H, Chikamori T, Igarashi Y, Harafuji K, Usui Y, Yanagisawa H, Hida S, Yamashina A, Nasr HA, Mahmoud SA, Dalipaj MM, Golanowski LN, Kemp RAD, Chow BJ, Beanlands RS, Ruddy TD, Michelena HI, Mikolich BM, McNelis P, Decker WAV, Stathopoulos I, Duncan SA, Isasi C, Travin MI, Kritzman JN, Ficaro EP, Corbett JR, Allison JS, Weinsaft JW, Wong FJ, Szulc M, Okin PM, Kligfield P, Harafuji K, Chikamori T, Igarashi Y, Tanaka H, Usui Y, Yanagisawa H, Hida S, Ishimaru S, Yamashima A, Giedd KN, Bergmann SR, Shah S, Emmett L, Allman KC, Magee M, Van Gaal W, Kritharides L, Freedman B, Abidov A, Gerlach J, Akincioglu C, Friedman J, Kavanagh P, Miranda R, Germano G, Berman DS, Hayes SW, Damera N, Lone B, Singh R, Shah A, Yeturi S, Prasad Y, Blum S, Heller EN, Bhalodkar NC, Koutelou M, Kollaros N, Theodorakos A, Manginas A, Leontiadis E, Kouzoumi A, Cokkinos D, Mazzanti M, Marini M, Cianci G, Perna GP, Pai M, Greenberg MD, Liu F, Frankenberger O, Kokkinos P, Hanumara D, Goheen E, Wu C, Panagiotakos D, Fletcher R, Greenberg MD, Liu F, Frankenberger O, Kokkinos P, Hanumara D, Goheen E, Rodriguez OJ, Iyer VN, Lue M, Hickey KT, Blood DK, Bergmann SR, Bokhari S, Chareonthaitawee P, Christensen SD, Allen JL, Kemp BJ, Hodge DO, Ritman EL, Gibbons RJ, Smanio P, Riva G, Rodriquez F, Tricoti A, Nakhlawi A, Thom A, Pretorius PH, King MA, Dahlberg S, Leppo J, Slomka PJ, Nishina H, Berman DS, Akincioglu C, Abidov A, Friedman JD, Hayes SW, Germano G, Petrovici R, Husain M, Lee DS, Nanthakumar K, Iwanochko RM, Brunken RC, DiFilippo F, Neumann DR, Bybel B, Herrington B, Bruckbauer T, Howe C, Lohmann K, Hayden C, Chatterjee C, Lathrop B, Brunken RC, Chen MS, Lohmann KA, Howe WC, Bruckbauer T, Kaczur T, Bybel B, DiFilippo FP, Druz RS, Akinboboye OA, Grimson R, Nichols KJ, Reichek N, Ngai K, Dim R, Ho KT, Pary S, Ahmed SU, Ahlberg A, Cyr G, Vitols PJ, Mann A, Alexander L, Rosenblatt J, Mieres J, Heller GV, Ahmed SU, Ahlberg AW, Cyr G, Navare S, O’Sullivan D, Heller GV, Chiadika S, Lue M, Blood DK, Bergmann SR, Bokhari S, Heston TF, Heller GV, Cerqueira MD, Jones PG, Bryngelson JR, Moutray KL, Gegen LL, Hertenstein GK, Moser K, Case JA, Zellweger MJ, Burger PC, Pfisterer ME, Mueller-Brand J, Kang WJ, Lee BI, Lee DS, Paeng JC, Lee JS, Chung JK, Lee MC, To BN, O’Connell WJ, Botvinick EH, Duvall WL, Croft LB, Einstein AJ, Fisher JE, Haynes PS, Rose RK, Henzlova MJ, Prasad Y, Vashist A, Blum S, Sagar P, Heller EN, Kuwabara Y, Nakayama K, Tsuru Y, Nakaya J, Shindo S, Hasegawa M, Komuro I, Liu YH, Wackers F, Natale D, DePuey G, Taillefer R, Araujo L, Kostacos E, Allen S, Delbeke D, Anstett F, Kansal P, Calvin JE, Hendel RC, Gulati M, Pratap P, Takalkar A, Kostacos E, Alavi A, Araujo L, Melduni RM, Duncan SA, Travin MI, Isasi CR, Rivero A, Santana C, Esiashvili S, Grossman G, Halkar R, Folks RD, Garcia EV, Su H, Dobrucki LW, Chow C, Hu X, Bourke BN, Cavaliere P, Hua J, Sinusas AJ, Spinale FG, Sweterlitsch S, Azure M, Edwards DS, Sudhakar S, Chyun DA, Young LH, Inzucchi SE, Davey JA, Wackers FJ, Noble GL, Navare SM, Calvert J, Hussain SA, Ahlberg AM, Katten DM, Boden WE, Heller GV, Shaw LJ, Yang Y, Antunes A, Botelho MF, Gomes C, de Lima JJP, Silva ML, Moreira JN, Simões S, GonÇalves L, Providência LA, Elhendy A, Bax JJ, Schinkel AF, Valkema R, van Domburg RT, Poldermans D, Arrighi J, Lampert R, Burg M, Soufer R, Veress AI, Weiss JA, Huesman RH, Gullberg GT, Moser K, Case JA, Loong CY, Prvulovich EM, Reyes E, Aswegen AV, Anagnostopoulos C, Underwood SR, Htay T, Mehta D, Sun L, Lacy J, Heo J, Brunken RC, Kaczur T, Jaber W, Ramakrishna G, Miller TD, O’connor MK, Gibbons RJ, Bural GG, Mavi A, Kumar R, El-Haddad G, Srinivas SM, A Alavi, El-Haddad G, Alavi A, Araujo L, Thomas GS, Johnson CM, Miyamoto MI, Thomas JJ, Majmundar H, Ryals LA, Ip ZTK, Shaw LJ, Bishop HA, Carmody JP, Greathouse WG, Yanagisawa H, Chikamori T, Tanaka H, Usui Y, Igarashi U, Hida S, Morishima T, Tanaka N, Takazawa K, Yamashina A, Diedrichs H, Weber M, Koulousakis A, Voth E, Schwinger RHG, Mohan HK, Livieratos L, Gallagher S, Bailey DL, Chambers J, Fogelman I, Sobol I, Barst RJ, Nichols K, Widlitz A, Horn E, Bergmann SR, Chen J, Galt JR, Durbin MK, Ye J, Shao L, Garcia EV, Mahenthiran J, Elliott JC, Jacob S, Stricker S, Kalaria VG, Sawada S, Scott JA, Aziz K, Yasuda T, Gewirtz H, Hsu BL, Moutray K, Udelson JE, Barrett RJ, Johnson JR, Menenghetti C, Taillefer R, Ruddy T, Hachamovitch R, Jenkins SA, Massaro J, Haught H, Lim CS, Underwood R, Rosman J, Hanon S, Shapiro M, Schweitzer P, VanTosh A, Jones S, Harafuji K, Giedd KN, Johnson NP, Berliner JI, Sciacca RR, Chou RL, Hickey KT, Bokhari SS, Rodriguez O, Bokhari S, Moser KW, Moutray KL, Koutelou M, Theodorakos A, Kollaros N, Manginas A, Leontiadis E, Cokkinos D, Mazzanti M, Marini M, Cianci G, Perna GP, Nanasato M, Fujita H, Toba M, Nishimura T, Nikpour M, Urowitz M, Gladman D, Ibanez D, Harvey P, Floras J, Rouleau J, Iwanochko R, Pai M, Guglin ME, Ginsberg FL, Reinig M, Parrillo JE, Cha R, Merhige ME, Watson GM, Oliverio JG, Shelton V, Frank SN, Perna AF, Ferreira MJ, Ferrer-Antunes AI, Rodrigues V, Santos F, Lima J, Cerqueira MD, Magram MY, Lodge MA, Babich JW, Dilsizian V, Line BR, Bhalodkar NC, Lone B, Singh R, Prasad Y, Yeturi S, Blum S, Heller EN, Rodriguez OJ, Skerrett D, Charles C, Shuster MD, Itescu S, Wang TS, Bruyant PP, Pretorius PH, Dahlberg S, King MA, Petrovici R, Iwanochko RM, Lee DS, Emmett L, Husain M, Hosokawa R, Ohba M, Kambara N, Tadamura E, Kubo S, Nohara R, Kita T, Thompson RC, McGhie AI, O’Keefe JH, Christenson SD, Chareonthaitawee P, Kemp BJ, Jerome S, Russell TJ, Lowry DR, Coombs VJ, Moses A, Gottlieb SO, Heiba SI, Yee G, Coppola J, Elmquist T, Braff R, Youssef I, Ambrose JA, Abdel-Dayem HM, Canto J, Dubovsky E, Scott J, Terndrup TE, Faber TL, Folks RD, Dim UR, Mclaughlin J, Pollepalle D, Schapiro W, Wang Y, Akinboboye O, Ngai K, Druz RS, Polepalle D, Phippen-Nater B, Leonardis J, Druz R. Abstracts of original contributions ASNC 2004 9th annual scientific session September 3-–October 3, 2004 New York, New York. J Nucl Cardiol 2004. [DOI: 10.1007/bf02974964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sadek M, Gholoum B, deKemp R, Dalipaj MM, Chow BJ, Beanlands RS, Ruddy TD. 1094-158 Altered myocardial perfusion with fatty meal ingestion in normal volunteers. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)91431-3] [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: 10/26/2022]
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Chow BJ, McKim DA, Shennib H, Dales RE. Superior vena cava obstruction secondary to mediastinal lymphadenopathy in a patient with cystic fibrosis. Chest 1997; 112:1438-41. [PMID: 9367491 DOI: 10.1378/chest.112.5.1438] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Superior vena cava (SVC) obstruction most often is a complication of malignant tumors such as lung cancer or lymphoma. The common use of long-term indwelling central venous catheters also has added to the prevalence of SVC obstruction. This report describes the first case of SVC obstruction in a patient with cystic fibrosis due to extrinsic compression from benign reactive mediastinal lymphadenopathy. Although in these circumstances intravascular thrombosis should be ruled out, extrinsic compression from mediastinal lymphadenopathy should be considered.
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Affiliation(s)
- B J Chow
- Department of Medicine and Respirology, University of Ottawa, Ontario, Canada
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