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Gomez-Stallons MV, Tretter JT, Hassel K, Gonzalez-Ramos O, Amofa D, Ollberding NJ, Mazur W, Choo JK, Smith JM, Kereiakes DJ, Yutzey KE. Calcification and extracellular matrix dysregulation in human postmortem and surgical aortic valves. Heart 2019; 105:1616-1621. [PMID: 31171628 DOI: 10.1136/heartjnl-2019-314879] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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: 02/11/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Calcific aortic valve disease (CAVD) is a progressive disease ranging from aortic valve (AoV) sclerosis to AoV stenosis (AS), characterised by severe calcification with impaired leaflet function. Due to the lack of early symptoms, the pathological progression towards valve dysfunction is poorly understood. The early patterns of AoV calcification and altered extracellular matrix (ECM) organisation were analysed in individuals postmortem without clinical AS compared with clinical AS. METHODS Histological patterns of calcification and ECM organisation in postmortem AoV leaflets without clinical AS obtained from a tissue repository and surgical specimens obtained from individuals with clinical AS were compared with in vivo imaging prior to transcatheter AoV implantation. RESULTS AoV calcification was detected in all samples from individuals >50 years old, with severity increasing with age, independent of known CAVD risk factors. Two distinct types of calcification were identified: 'Intrinsic', primarily found at the leaflet hinge of postmortem leaflets, accompanied by abnormal collagen and proteoglycan deposition; and 'Nodular', extending from the middle to the tip regions in more severely affected postmortem leaflets and surgical specimens, associated with increased elastin fragmentation and loss of elastin integrity. Even in the absence of increased thickening, abnormalities in ECM composition were observed in postmortem leaflets without clinical AS and worsen in clinical AS. CONCLUSIONS Two distinct phenotypes of AoV calcification are apparent. While the 'nodular' form is recognised on in vivo imaging and is present with CAVD and valve dysfunction, it is unclear if the 'intrinsic' form is pathological or detected on in vivo imaging.
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Affiliation(s)
- M Victoria Gomez-Stallons
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Justin T Tretter
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Keira Hassel
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Osniel Gonzalez-Ramos
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dorothy Amofa
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Wojciech Mazur
- The Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio, USA
| | - Joseph K Choo
- The Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio, USA
| | | | - Dean J Kereiakes
- The Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio, USA
| | - Katherine E Yutzey
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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2
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Affiliation(s)
- Geraldine Ong
- Department of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Philippe Pibarot
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
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3
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Zhang W, Pei F, Wan J. Intracardiac mass in a 66-year-old woman. Heart 2019; 105:1062-1128. [PMID: 30923174 DOI: 10.1136/heartjnl-2018-314600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/31/2019] [Accepted: 02/17/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- Wei Zhang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Fei Pei
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Junzhe Wan
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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4
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Affiliation(s)
| | - Christina Stewart
- Department of Medical Physics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicholas W Weir
- Department of Medical Physics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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5
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Loganath K, Shambrook J, Moss AJ. A 49-year-old with chest pain and bioprosthetic aortic valve. Heart 2019; 105:981-1033. [PMID: 30723099 DOI: 10.1136/heartjnl-2018-314468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 12/24/2018] [Indexed: 11/03/2022] Open
Affiliation(s)
- Krithika Loganath
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - James Shambrook
- Department of Radiology, University Hospital Southampton, Southampton, UK
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6
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Konishi T, Murakami H, Tanaka S. Woman in her 50s with shortness of breath on exertion. Heart 2018; 105:110. [PMID: 30093542 DOI: 10.1136/heartjnl-2018-313655] [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: 06/12/2018] [Revised: 07/10/2018] [Accepted: 07/26/2018] [Indexed: 11/04/2022] Open
Abstract
CLINICAL INTRODUCTION A 59-year-old woman visited an outpatient cardiology clinic due to shortness of breath on exertion. Physical examination showed no significant abnormality of vital signs. A III/VI systolic murmur was heard on the fourth intercostal space at the right sternal border. The majority of laboratory tests were normal. Chest X-ray showed a curved vessel shadow (figure 1A). Initial transthoracic echocardiography showed abnormal blood flow into the inferior vena cava (IVC) in the subxiphoid long axis view (figure 1B) and mild right heart dilatation (online supplementary figure 1). Transoesophageal echocardiography showed severe tricuspid regurgitation (online supplementary figure 2).heartjnl;105/2/110/F1F1F1Figure 1(A) Chest X-ray. (B) Colour Doppler image in the subxiphoid long axis view.DC1SP110.1136/heartjnl-2018-313655.supp1Supplementary data DC2SP210.1136/heartjnl-2018-313655.supp2Supplementary data QUESTION: What is the most likely underlying disease for the patient's shortness of breath on exertion?Pulmonary arteriovenous fistula.Pulmonary arterial hypertension.Lung cancer.Partial anomalous pulmonary venous connection.Isolated tricuspid regurgitation.
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Affiliation(s)
- Takao Konishi
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan.,Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hironori Murakami
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Shinya Tanaka
- Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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7
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Opolski MP, Gransar H, Lu Y, Achenbach S, Al-Mallah MH, Andreini D, Bax JJ, Berman DS, Budoff MJ, Cademartiri F, Callister TQ, Chang HJ, Chinnaiyan K, Chow BJ, Cury RC, DeLago A, Feuchtner GM, Hadamitzky M, Hausleiter J, Kaufmann PA, Kim YJ, Leipsic JA, Maffei EC, Marques H, Pontone G, Raff G, Rubinshtein R, Shaw LJ, Villines TC, Gomez M, Jones EC, Peña JM, Min JK, Lin FY. Prognostic value of chronic total occlusions detected on coronary computed tomographic angiography. Heart 2018; 105:196-203. [PMID: 30061160 DOI: 10.1136/heartjnl-2017-312907] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 12/22/2017] [Revised: 06/19/2018] [Accepted: 06/22/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Data describing clinical relevance of chronic total occlusion (CTO) identified by coronary CT angiography (CCTA) have not been reported to date. We investigated the prognosis of CTO on CCTA. METHODS We identified 22 828 patients without prior known coronary artery disease (CAD), who were followed for a median of 26 months. Based on CCTA, coronary lesions were graded as normal (no atherosclerosis), non-obstructive (1%-49%), moderate-to-severe (50%-99%) or totally occluded (100%). All-cause mortality, and major adverse cardiac events defined as mortality, non-fatal myocardial infarction and late coronary revascularisation (≥90 days after CCTA) were assessed. RESULTS The distribution of patients with normal coronaries, non-obstructive CAD, moderate-to-severe CAD and CTO was 10 034 (44%), 7965 (34.9%), 4598 (20.1%) and 231 (1%), respectively. The mortality rate per 1000 person-years of CTO patients was non-significantly different from patients with moderate-to-severe CAD (22.95; 95% CI 12.71 to 41.45 vs 14.46; 95% CI 12.34 to 16.94; p=0.163), and significantly higher than of those with normal coronaries and non-obstructive CAD (p<0.001 for both). Among 14 382 individuals with follow-up for the composite end point, patients with CTO had a higher rate of events than those with moderate-to-severe CAD (106.56; 95% CI 76.51 to 148.42 vs 65.45; 95% CI 58.01 to 73.84, p=0.009). This difference was primarily driven by an increase in late revascularisations in CTO patients (27 of 35 events). After multivariable adjustment, compared with individuals with normal coronaries, the presence of CTO conferred the highest risk for adverse cardiac events (14.54; 95% CI 9.11 to 23.20, p<0.001). CONCLUSIONS The detection of CTO on non-invasive CCTA is associated with increased rate of late revascularisation but similar 2-year mortality as compared with moderate-to-severe CAD. TRIAL REGISTRATION NUMBER NCT01443637.
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Affiliation(s)
- Maksymilian P Opolski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Heidi Gransar
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yao Lu
- Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
| | | | - Mouaz H Al-Mallah
- King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Riyadh, Saudi Arabia
| | - Daniele Andreini
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, HARTZ, Leiden, The Netherlands
| | - Daniel S Berman
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California, USA
| | - Filippo Cademartiri
- Department of Radiology, SDN IRCCS Cardiovascular Imaging Center, Naples, Italy
| | - Tracy Q Callister
- Tennessee Heart and Vascular Institute, Hendersonville, Tennessee, USA
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Kavitha Chinnaiyan
- Department of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan, USA
| | - Benjamin Jw Chow
- Department of Medicine and Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Ricardo C Cury
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | | | - Gudrun M Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
| | - Joerg Hausleiter
- Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erica C Maffei
- Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy
| | - Hugo Marques
- UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal
| | - Gianluca Pontone
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy
| | - Gilbert Raff
- Department of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan, USA
| | - Ronen 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
| | - Leslee J Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Todd C Villines
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Millie Gomez
- Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
| | - Erica C Jones
- Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
| | - Jessica M Peña
- Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
| | - James K Min
- Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
| | - Fay Y Lin
- Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
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Abstract
CLINICAL INTRODUCTION A 32-year old man was referred to our institution for transthoracic echocardiography (TTE) following detection of an incidental murmur on physical examination before blood donation. He was asymptomatic with no significant medical history. Physical examination revealed dual heart sounds with a grade II/VI systolic murmur heard in the left sternal border. An ECG was in normal sinus rhythm. TTE was performed (figure 1A-C, online supplementary videos 1-4) followed by cardiac CT angiography (CTA) (figure 1D,E).heartjnl;104/15/1307/F1F1F1Figure 1(A) Transthoracic echocardiography, parasternal left ventricular long axis view. (B) Colour Doppler of modified short axis in the mid-left ventricular level. (C) Doppler flow velocity profile. (D) Cardiac CT angiography (CTA) sagittal reconstruction. (E) Three-dimensional CTA reconstruction of the heart. QUESTION What is the diagnosis?Pericardial cyst.Ventricular septal defect.Kawasaki.Anomalous left coronary artery from pulmonary artery (ALCAPA).
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Affiliation(s)
- Maryam Shojaeifard
- Echocardiography Department, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | | | - Golnaz Houshmand
- Echocardiography Department, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
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9
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Affiliation(s)
- Ibrahim Akin
- Cardiology, Universitätsmedizin Mannheim, Mannheim, Germany
- DZHK, DZHK (Deutsches Zentrum für Herz-Kreislaufforschung), Mannheim, Germany
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton Hospital and Harefield Trust, London, UK
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10
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Nakao YM, Miyamoto Y, Higashi M, Noguchi T, Ohishi M, Kubota I, Tsutsui H, Kawasaki T, Furukawa Y, Yoshimura M, Morita H, Nishimura K, Kada A, Goto Y, Okamura T, Tei C, Tomoike H, Naito H, Yasuda S. Sex differences in impact of coronary artery calcification to predict coronary artery disease. Heart 2018; 104:1118-1124. [PMID: 29331986 PMCID: PMC6031260 DOI: 10.1136/heartjnl-2017-312151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/17/2017] [Accepted: 11/28/2017] [Indexed: 01/01/2023] Open
Abstract
Objective To assess sex-specific differences regarding use of conventional risks and coronary artery calcification (CAC) to detect coronary artery disease (CAD) using coronary CT angiography (CCTA). Methods The Nationwide Gender-specific Atherosclerosis Determinants Estimation and Ischemic Cardiovascular Disease Prospective Cohort study is a prospective, multicentre, nationwide cohort study. Candidates with suspected CAD aged 50–74 years enrolled from 2008 to 2012. The outcome was obstructive CAD defined as any stenosis ≥50% by CCTA. We constructed logistic regression models for obstructive CAD adjusted for conventional risks (clinical model) and CAC score. Improvement in discrimination beyond risks was assessed by C-statistic; net reclassification index (NRI) for CAD probability of low (<30%), intermediate (30%–60%) and high (≥60%); and risk stratification capacity. Results Among 991 patients (456 women, 535 men; 65.2 vs 64.4 years old), women had lower CAC scores (median, 4 vs 60) and lower CAD prevalence (21.7% vs 37.0%) than men. CAC significantly improved model discrimination compared with clinical model in both sexes (0.66–0.79 in women vs 0.61–0.83 in men). The NRI for women was 0.33, which was much lower than that for men (0.71). Adding CAC to clinical model had a larger benefit in terms of moving an additional 43.3% of men to the most determinant categories (high or low risk) compared with −1.4% of women. Conclusions The addition of CAC to a prediction model based on conventional variables significantly improved the classification of risk in suspected patients with CAD, with sex differences influencing the predictive ability. Trial registration number UMIN-CTR Clinical Trial: UMIN000001577.
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Affiliation(s)
- Yoko M Nakao
- Department of Preventive Medicine and Epidemiologic informatics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiro Miyamoto
- Department of Preventive Medicine and Epidemiologic informatics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medicine Kagoshima University, Kagoshima, Japan
| | - Isao Kubota
- Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hideaki Morita
- Department of Cardiology, Osaka Medical College, Osaka, Japan
| | - Kunihiro Nishimura
- Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yoichi Goto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomonori Okamura
- Department of Preventive Medicine and Public Health, Keio University, Tokyo, Japan
| | - Chuwa Tei
- Waon Therapy Research Institute, Tokyo, Japan
| | | | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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11
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Dreisbach JG, Nicol ED, Roobottom CA, Padley S, Roditi G. Challenges in delivering computed tomography coronary angiography as the first-line test for stable chest pain. Heart 2017; 104:921-927. [PMID: 29138258 PMCID: PMC5969350 DOI: 10.1136/heartjnl-2017-311846] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/20/2017] [Accepted: 09/21/2017] [Indexed: 12/18/2022] Open
Abstract
Objective The National Institute for Health and Care Excellence (NICE) clinical guidelines ‘chest pain of recent onset: assessment and diagnosis’ (update 2016) state CT coronary angiography (CTCA) should be offered as the first-line investigation for patients with stable chest pain. However, the current provision in the UK is unknown. We aimed to evaluate this and estimate the requirements for full implementation of the guidelines including geographical variation. Ancillary aims included surveying the number of CTCA-capable scanners and accredited practitioners in the UK. Methods The number of CTCA scans performed annually was surveyed across the National Health Service (NHS). The number of percutaneous coronary interventions performed for stable angina in the NHS in 2015 was applied to a model based on SCOT-HEART (CTCA in patients with suspected angina due to coronary heart disease: an open-label, parallel-group, multicentre trial) data to estimate the requirement for CTCA, for full guideline implementation. Details of CTCA-capable scanners were obtained from manufacturers and formally accredited practitioner details from professional societies. Results An estimated 42 340 CTCAs are currently performed annually in the UK. We estimate that 350 000 would be required to fully implement the guidelines. 304 CTCA-capable scanners and 198 accredited practitioners were identified. A marked geographical variation between health regions was observed. Conclusions This study provides insight into the scale of increase in the provision of CTCA required to fully implement the updated NICE guidelines. A small specialist workforce and limited number of CTCA-capable scanners may present challenges to service expansion.
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Affiliation(s)
| | - Edward D Nicol
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | | | - Simon Padley
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Giles Roditi
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, UK
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12
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Abstract
Clinical introduction A retired 59-year-old woman presented to the cardiology clinic concerned with cardiac pulsations that were visible on her chest wall. These were not associated with dyspnoea, syncope or chest discomfort. Of note, 8 years previously, she complained of recurrent nocturnal diaphoresis and 5 kg weight loss. Blood sampling at that time revealed a microcytic anaemia, reactive thrombocytosis and raised inflammatory markers (erythrocyte sedimentation rate 99 mm/hour, C-reactive protein 161 mg/L). Following an episode of transient diplopia, ophthalmoscopy demonstrated a cotton wool spot in the left inferotemporal retinal arcade. She commenced a 2-year tapering course of 1 mg/kg prednisolone. On examination, she had a lean physique with a supine blood pressure of 162/60 mm Hg and palpable Corrigan’s pulse. She had a prominent apical pulsation and a loud early diastolic murmur was present at the left sternal edge radiating to the apex. Echocardiography showed severe central aortic regurgitation and a dilated aortic root (see online supplementary figure 1). Cardiac CT was performed to clarify the diagnosis (figure 1). Question Which of the following diagnoses best explains this presentation?Ankylosing spondylitis Takayasu arteritis Salmonellosis IgG4-related aortitis Giant cell aortitis
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Affiliation(s)
- Alastair J Moss
- Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Renzo Pessotto
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D Flapan
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
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13
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Ford TJ, Corcoran D, Berry C. Stable coronary syndromes: pathophysiology, diagnostic advances and therapeutic need. Heart 2017; 104:284-292. [PMID: 29030424 PMCID: PMC5861393 DOI: 10.1136/heartjnl-2017-311446] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 12/13/2022]
Abstract
The diagnostic management of patients with angina pectoris typically centres on the detection of obstructive epicardial CAD, which aligns with evidence-based treatment options that include medical therapy and myocardial revascularisation. This clinical paradigm fails to account for the considerable proportion (approximately one-third) of patients with angina in whom obstructive CAD is excluded. This common scenario presents a diagnostic conundrum whereby angina occurs but there is no obstructive CAD (ischaemia and no obstructive coronary artery disease—INOCA). We review new insights into the pathophysiology of angina whereby myocardial ischaemia results from a deficient supply of oxygenated blood to the myocardium, due to various combinations of focal or diffuse epicardial disease (macrovascular), microvascular dysfunction or both. Macrovascular disease may be due to the presence of obstructive CAD secondary to atherosclerosis, or may be dynamic due to a functional disorder (eg, coronary artery spasm, myocardial bridging). Pathophysiology of coronary microvascular disease may involve anatomical abnormalities resulting in increased coronary resistance, or functional abnormalities resulting in abnormal vasomotor tone. We consider novel clinical diagnostic techniques enabling new insights into the causes of angina and appraise the need for improved therapeutic options for patients with INOCA. We conclude that the taxonomy of stable CAD could improve to better reflect the heterogeneous pathophysiology of the coronary circulation. We propose the term ‘stable coronary syndromes’ (SCS), which aligns with the well-established terminology for ‘acute coronary syndromes’. SCS subtends a clinically relevant classification that more fully encompasses the different diseases of the epicardial and microvascular coronary circulation.
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Affiliation(s)
- Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,University of New South Wales, Sydney, NSW, Australia
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,British Society of Cardiovascular Research, Glasgow, UK
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14
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Affiliation(s)
- Ashvarya Mangla
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica K Bjorklund
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Dinesh K Kalra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
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