Abstract Objectives This study sought to develop a clinical model that identifies patients with and without high-risk coronary artery disease (CAD). Background Although current clinical models help ...to estimate a patient's pre-test probability of obstructive CAD, they do not accurately identify those patients with and without high-risk coronary anatomy. Methods Retrospective analysis of a prospectively collected multinational coronary computed tomographic angiography (CTA) cohort was conducted. High-risk anatomy was defined as left main diameter stenosis ≥50%, 3-vessel disease with diameter stenosis ≥70%, or 2-vessel disease involving the proximal left anterior descending artery. Using a cohort of 27,125, patients with a history of CAD, cardiac transplantation, and congenital heart disease were excluded. The model was derived from 24,251 consecutive patients in the derivation cohort and an additional 7,333 nonoverlapping patients in the validation cohort. Results The risk score consisted of 9 variables: age, sex, diabetes, hypertension, current smoking, hyperlipidemia, family history of CAD, history of peripheral vascular disease, and chest pain symptoms. Patients were divided into 3 risk categories: low (≤7 points), intermediate (8 to 17 points) and high (≥18 points). The model was statistically robust with area under the curve of 0.76 (95% confidence interval CI: 0.75 to 0.78) in the derivation cohort and 0.71 (95% CI: 0.69 to 0.74) in the validation cohort. Patients who scored ≤7 points had a low negative likelihood ratio (<0.1), whereas patients who scored ≥18 points had a high specificity of 99.3% and a positive likelihood ratio (8.48). In the validation group, the prevalence of high-risk CAD was 1% in patients with ≤7 points and 16.7% in those with ≥18 points. Conclusions We propose a scoring system, based on clinical variables, that can be used to identify patients at high and low pre-test probability of having high-risk CAD. Identification of these populations may detect those who may benefit from a trial of medical therapy and those who may benefit most from an invasive strategy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Studies examining coronary computed tomographic angiography (CCTA) have demonstrated increased mortality related to coronary artery disease (CAD) severity but are limited to relatively nondiverse ...ethnic populations. The aim of this study was to evaluate the prognostic significance of CAD on CCTA according to ethnicity for patients without previous CAD in a prospective international CCTA registry of 11 sites (7 countries) who underwent 64-slice CCTA from 2005 to 2010. CAD was defined as any coronary artery atherosclerosis and obstructive CAD as ≥50% stenosis. All-cause mortality and nonfatal myocardial infarction (MI) were assessed by ethnicity using Kaplan-Meier and Cox proportional hazards, controlling for baseline risk factors, medications, and revascularization. A total of 16,451 patients of mean age 58 years (55% men) were followed over a median of 2.0 years (interquartile range 1.4 to 3.2). Patients were 60.1% Caucasian, 34.4% East Asian, and 5.5% African. Death or MI occurred in 0.5% (38 of 7,109) among patients with no CAD, 1.6% (91 of 5,600) among those with nonobstructive CAD, and 3.8% (142 of 3,742) among those with ≥50% stenosis (p <0.001 among all groups). The annualized incidence of death or MI comparing obstructive to no obstructive CAD among Caucasians was 2.2% versus 0.7% (adjusted hazard ratio aHR 2.77, 95% confidence interval CI 1.73 to 4.43, p <0.001), among Africans 4.8% versus 1.1% (aHR 6.25, 95% CI 1.12 to 34.97, p = 0.037), and among East Asians 0.8% versus 0.1% (aHR 4.84, 95% CI 2.24 to 10.9, p <0.001). Compared to other ethnicities, East Asians had fewer than expected events (aHR 0.25, 95% CI 0.16 to 0.38, p <0.001). In conclusion, the presence and severity of CAD visualized by CCTA predict death or MI across 3 large ethnicities, whereas normal results on CCTA identify patients at very low risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background In patients with chronic angina-like chest pain, the probability of coronary artery disease (CAD) is estimated by symptoms, age, and sex according to the Genders clinical model. ...We investigated the incremental value of circulating biomarkers over the Genders model to predict functionally significant CAD in patients with chronic chest pain. Methods In 527 patients (60.4 years, standard deviation, 8.9 years; 61.3% male participants) enrolled in the European Ev aluation of In tegrated Cardiac I maging (EVINCI) study, clinical and biohumoral data were collected. Results Functionally significant CAD—ie, obstructive coronary disease seen at invasive angiography causing myocardial ischemia at stress imaging or associated with reduced fractional flow reserve (FFR < 0.8), or both—was present in 15.2% of patients. High-density lipoprotein (HDL) cholesterol, aspartate aminotransferase (AST) levels, and high-sensitivity C-reactive protein (hs-CRP) were the only independent predictors of disease among 31 biomarkers analyzed. The model integrating these biohumoral markers with clinical variables outperformed the Genders model by receiver operating characteristic curve (ROC) (area under the curve AUC, 0.70 standard error (SE), 0.03 vs 0.58 SE, 0.03, respectively, P < 0.001) and reclassification analysis (net reclassification improvement, 0.15 SE, 0.07; P = 0.04). Cross-validation of the ROC analysis confirmed the discrimination ability of the new model (AUC, 0.66). As many as 56% of patients who were assigned to a higher pretest probability by the Genders model were correctly reassigned to a low probability class (< 15%) by the new integrated model. Conclusions The Genders model has a low accuracy for predicting functionally significant CAD. A new model integrating HDL cholesterol, AST, and hs-CRP levels with common clinical variables has a higher predictive accuracy for functionally significant CAD and allows the reclassification of patients from an intermediate/high to a low pretest likelihood of CAD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
A panoramic view integrating stress 99mTc-tetrofosmin myocardial perfusion imaging and coronary computed tomography angiography confirmed a giant tortuous LCX (C) draining into the right atrium (D, ...black arrow) with a basal inferior ischemia secondary to coronary steal phenomena in the border zone between LCX and RCA territory (E) (Online Video 3).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Limited data have been published on the normal size of the ascending aorta (AA) measured using transthoracic echocardiography (TTE).
AA diameters were measured in 1799 patients with normal cardiac ...findings on TTE and compared with the diameters of the sinus of Valsalva (SoV).
Mean diameters in men and women, respectively, were 3.4 and 3.1 cm for the SoV and 3.2 and 3.0 cm for the AA. The sizes of the SoV and the AA showed strong correlations with age, age squared, and body surface area. The 5th and 95th percentile curves for the SoV and AA showed faster growth of diameters in early adulthood compared with old age. The dimensions of the SoV were larger than those of the AA (mean differences, 0.19 cm in men and 0.08 cm in women), and the difference between the SoV and AA was negatively correlated with age.
The findings of this study stress the importance of indexing dimensions of the SoV and the AA to age and body surface area separately for men and women.
The past few years have witnessed impressive advances in the field of noninvasive cardiac imaging. For example, computed tomography (CT) coronary angiography has been adopted into daily clinical ...routine and, at least in some patient populations, is challenging the role of invasive angiography as the anatomic standard of reference. This is because the latter is associated with a nonnegligible periprocedural morbidity and mortality, which suggests confining its use to patients who will benefit from a revascularization procedure. Many factors that are beyond the quantification of anatomic narrowing and therefore cannot be fully appreciated with morphologic assessment will eventually determine whether or not a given lesion produces stress-induced ischemia. Myocardial perfusion imaging with single-photon emission computed tomography (SPECT) is among the most widely used and well-established noninvasive tools for the diagnosis of ischemic coronary disease. It allows assessment of the physiological relevance of coronary lesions and offers a high prognostic predictive value. Although positron emission tomography (PET) may achieve a higher accuracy than SPECT, its use has so far often been limited to large centers. Recent advances in image processing software and the advent of hybrid scanners have paved the way for fusion of image datasets from different modalities. An ideal, noninvasive technique for the diagnosis of coronary artery disease should provide complementary information on coronary anatomy as well as on pathophysiologic lesion severity. SPECT/CT and PET/CT hybrid imaging can provide such unique information, which not only improves diagnostic assessment and risk stratification but may also guide decision making with regard to revascularization in patients with coronary artery disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objectives We sought to assess the feasibility of prospective electrocardiogram triggering for achieving low-dose computed tomography coronary angiography (CTCA) in a large population. Background ...Prospective electrocardiogram triggering dramatically reduces radiation exposure for CTCA but requires heart rate (HR) control to obtain diagnostic image quality. Its feasibility in daily clinical routine has therefore remained to be elucidated. Methods We evaluated 612 patients consecutively referred for CTCA by 64-slice computed tomography. Intravenous metoprolol (2 to 30 mg) was administered if necessary to achieve a target HR below 65 beats/min. Image quality was assessed on a semiquantitative 4-point scale for each coronary segment. Results Forty-six (7.5%) patients were deemed ineligible due to irregular heart rhythm (n = 19), insufficient response to metoprolol (n = 21), renal insufficiency (n = 3), or inability to follow breath-hold commands (n = 3). Mean effective radiation dose was 1.8 ± 0.6 mSv with a diagnostic image quality in 96.2% of segments. Finally, low-dose CTCA allowed a firm diagnosis with regard to the presence or absence of coronary artery disease in 527 (86.1%) patients. Intravenous metoprolol to achieve an HR below 65 beats/min was used in 64.4% of patients. Incidence of nondiagnostic segments was inversely related to HR (r = −0.809, p < 0.001). Below an HR cutoff of 62 beats/min, only 1.2% of coronary segments were nondiagnostic. Conclusions Low-dose CTCA by electrocardiogram triggering is feasible in the vast majority of an every-day population. However, HR control is crucial, as an HR below 62 beats/min favors diagnostic image quality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Patients with chronic kidney disease have a worse cardiovascular prognosis than those without. The aim of this study was to determine the incremental prognostic value of coronary computed tomographic ...angiography in predicting mortality across the entire spectrum of renal function in patients with known or suspected coronary artery disease (CAD). A large international multicenter registry was queried, and patients with left ventricular ejection fraction (LVEF) and creatinine data were screened. National Cholesterol Education Program Adult Treatment Panel III risk was calculated. Coronary computed tomographic angiographic results were evaluated for CAD severity (normal, nonobstructive, or obstructive) and an LVEF <50%. Patients were followed for the end point of all-cause mortality. Among 5,655 patients meeting the study criteria, follow-up was available for 5,572 (98.9%; median follow-up duration 18.6 months). All-cause mortality (66 deaths) significantly increased with every 10-unit decrease in renal function (hazard ratio HR 1.23, 95% confidence interval CI 1.07 to 1.41). All-cause mortality occurred in 0.33% of patients without coronary atherosclerosis, 1.82% of patients with nonobstructive CAD, and 2.43% of patients with obstructive CAD. Multivariate Cox proportional-hazards models revealed that impaired renal function (HR 2.29, 95% CI 1.65 to 3.18), CAD severity (HR 1.81, 95% CI 1.31 to 2.51), and an abnormal LVEF (HR 4.16, 95% CI 2.45 to 7.08) were independent predictors of all-cause mortality. In conclusion, coronary computed tomographic angiographic measures of CAD severity and the LVEF provide effective risk stratification across a wide spectrum of renal function. Furthermore, renal dysfunction, CAD severity, and the LVEF have additive value for predicting all-cause death in patients with suspected obstructive CAD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The aim of this study was to compare the diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTCA) in groups of patients with low, intermediate, and high risk for coronary ...artery disease (CAD) events.
The institutional review board approved this study; written informed consent was obtained from all patients. Eighty-eight consecutive patients with suspected CAD (40 women; mean age, 64.3 +/- 9.4 years; range, 39-82) underwent CTCA, calcium scoring, and invasive coronary angiography and were grouped according to their Framingham 10-year risk for hard coronary events into low (<10%), intermediate (10%-20%), and high (>20%) risk categories. Significant stenoses (luminal diameter narrowing > or =50%) were assessed on an intention-to-diagnose-basis; no coronary segment was excluded and nonevaluative segments were rated false positive. To determine differences between groups, Kruskal-Wallis tests were performed for individually determined values of diagnostic performance.
Per-patient sensitivity, specificity, negative predictive, and positive predictive values were 90.0%, 79.2%, 95.0%, and 64.3%, respectively, with low (n = 34), 87.5%, 92.3%, 85.7%, and 93.3%, respectively, with intermediate (n = 29), and 100%, 75.0%, 100%, and 89.5%, respectively, with high risk (n = 25), with a trend toward higher positive predictive value (P = .07). Per-segment negative predictive value was lower with high pretest probability (P < .01). Mean calcium-score units were 90, 220, and 312 (P = .23), and the prevalence of CAD was 29.4%, 55.2%, and 68.0% (P < .01) with low, intermediate, and high risk.
Sensitivity and specificity of CTCA are not influenced by the prevalence of CAD, whereas the negative predictive value is lower and the positive predictive value tends to be higher in patients with a high prevalence of CAD.
Chronic kidney disease (CKD) is associated with cardiovascular (CV) events caused by advanced atherosclerosis. Computed tomographic coronary angiography (CTA) can accurately diagnose coronary artery ...disease (CAD) and predict CV outcomes. The aim of the present study was to evaluate whether moderate CKD provides prognostic information for CV events in patients undergoing CTA. In total 885 patients with suspected CAD underwent CTA and were stratified to moderate CKD (85 patients) or no CKD (770 patients) based on a cut-off estimated glomerular filtration rate of 60 ml/min/1.73 m2 . After 896 days of follow-up, 42 patients developed CV events. Annualized CV event rates were 1.2% in patients with no CKD and no CAD, 2.5% in patients with moderate CKD alone, 2.5% in patients with obstructive CAD alone, and 3.7% in those with moderate CKD and obstructive CAD. Multivariate models demonstrated that moderate CKD (hazard ratio 2.39, confidence interval 1.09 to 5.21, p = 0.03) and obstructive CAD (hazard ratio 2.76, confidence interval 1.40 to 5.44, p <0.01) were independent predictors of CV events. Importantly, moderate CKD provided incremental prognostic information in addition to clinical characteristics and obstructive CAD (chi-square 49.4, p = 0.04). In conclusion, moderate CKD was associated with CV events and provided incremental prognostic information.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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