Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute ...coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.
Abstract Background In a prospective, multicenter, randomized controlled trial, 4,146 patients were randomized to receive standard care or standard care plus coronary computed tomography angiography ...(CCTA). Objectives The purpose of this study was to explore the consequences of CCTA-assisted diagnosis on invasive coronary angiography, preventive treatments, and clinical outcomes. Methods In post hoc analyses, we assessed changes in invasive coronary angiography, preventive treatments, and clinical outcomes using national electronic health records. Results Despite similar overall rates (409 vs. 401; p = 0.451), invasive angiography was less likely to demonstrate normal coronary arteries (20 vs. 56; hazard ratios HRs: 0.39 95% confidence interval (CI): 0.23 to 0.68; p < 0.001) but more likely to show obstructive coronary artery disease (283 vs. 230; HR: 1.29 95% CI: 1.08 to 1.55; p = 0.005) in those allocated to CCTA. More preventive therapies (283 vs. 74; HR: 4.03 95% CI: 3.12 to 5.20; p < 0.001) were initiated after CCTA, with each drug commencing at a median of 48 to 52 days after clinic attendance. From the median time for preventive therapy initiation (50 days), fatal and nonfatal myocardial infarction was halved in patients allocated to CCTA compared with those assigned to standard care (17 vs. 34; HR: 0.50 95% CI: 0.28 to 0.88; p = 0.020). Cumulative 6-month costs were slightly higher with CCTA: difference $462 (95% CI: $303 to $621). Conclusions In patients with suspected angina due to coronary heart disease, CCTA leads to more appropriate use of invasive angiography and alterations in preventive therapies that were associated with a halving of fatal and non-fatal myocardial infarction. (Scottish COmputed Tomography of the HEART Trial SCOT-HEART; NCT01149590 )
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IMPORTANCE: Use of intravascular ultrasound (IVUS) promotes better clinical outcomes for coronary intervention in complex coronary lesions. However, randomized data demonstrating the clinical ...usefulness of IVUS are limited for lesions treated with drug-eluting stents. OBJECTIVE: To determine whether the long-term clinical outcomes with IVUS-guided drug-eluting stent implantation are superior to those with angiography-guided implantation in patients with long coronary lesions. DESIGN, SETTING, AND PARTICIPANTS: The Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions (IVUS-XPL) randomized, multicenter trial was conducted in 1400 patients with long coronary lesions (implanted stent ≥28 mm in length) between October 2010 and July 2014 at 20 centers in Korea. INTERVENTIONS: Patients were randomly assigned to receive IVUS-guided (n = 700) or angiography-guided (n = 700) everolimus-eluting stent implantation. MAIN OUTCOMES AND MEASURES: Primary outcome measure was the composite of major adverse cardiac events, including cardiac death, target lesion-related myocardial infarction, or ischemia-driven target lesion revascularization at 1 year, analyzed by intention-to-treat. RESULTS: One-year follow-up was complete in 1323 patients (94.5%). Major adverse cardiac events at 1 year occurred in 19 patients (2.9%) undergoing IVUS-guided and in 39 patients (5.8%) undergoing angiography-guided stent implantation (absolute difference, −2.97% 95% CI, −5.14% to −0.79%) (hazard ratio HR, 0.48 95% CI, 0.28 to 0.83, P = .007). The difference was driven by a lower risk of ischemia-driven target lesion revascularization in patients undergoing IVUS-guided (17 2.5%) compared with angiography-guided (33 5.0%) stent implantation (HR, 0.51 95% CI, 0.28 to 0.91, P = .02). Cardiac death and target lesion–related myocardial infarction were not significantly different between the 2 groups. For cardiac death, there were 3 patients (0.4%) in the IVUS-guided group and 5 patients (0.7%) in the angiography-guided group (HR, 0.60 95% CI, 0.14 to 2.52, P = .48). Target lesion–related myocardial infarction occurred in 1 patient (0.1%) in the angiography-guided stent implantation group (P = .32). CONCLUSIONS AND RELEVANCE: Among patients requiring long coronary stent implantation, the use of IVUS-guided everolimus-eluting stent implantation, compared with angiography-guided stent implantation, resulted in a significantly lower rate of the composite of major adverse cardiac events at 1 year. These differences were primarily due to lower risk of target lesion revascularization. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01308281
The present analysis addresses the potential clinical and physiologic significance of discordance in severity of coronary artery disease between the angiogram and fractional flow reserve (FFR) in a ...large and unselected patient population.
Between September 1999 and December 2011, FFR and percent diameter stenosis (DS) as assessed by quantitative coronary angiography were obtained in 2986 patients (n = 4086 coronary stenoses), in whom at least one stenosis was of intermediate angiographic severity. Fractional flow reserve correlated slightly but significantly with DS -0.38 (95% CI: -0.41; -0.36); P < 0.001. The sensitivity, specificity, and diagnostic accuracy of a ≥ 50% DS for predicting FFR ≤ 0.80 were 61% (95% CI: 59; 63), 67% (95% CI: 65; 69), and 0.64 (95% CI: 0.56; 0.72), respectively. In different anatomical settings, sensitivity and specificity showed marked variations between 35 to 74% and 58 to 76%, respectively, resulting in a discordance in 35% of all cases for these thresholds. For an angiographic threshold of 70% DS, the diagnostic performance by the Youden's index decreased from 0.28 to 0.11 for the overall population.
The data confirm that one-third of a large patient population shows discordance between angiogram ≥ 50%DS and FFR ≤ 0.8 thresholds of stenosis severity. Left main stenoses are often underestimated by the classical 50% DS cut-off compared with FFR. This discordance offers physiologic insights for future trials. It is hypothesized that the discordance between angiography and FFR is related to technical limitations, such as imprecise luminal border detection by angiography, as well as to physiologic factors, such as variable minimal microvascular resistance.
In the last decades, radial access, as an alternative to femoral access, has rapidly evolved and emerged as the preferred vascular access for coronary angiography and percutaneous coronary ...intervention (PCI). The use of radial access for PCI can reduce access-site bleeding, particularly retroperitoneal bleeding, and risk of developing pseudoaneurysm, while also improving patient comfort after procedure (eg, early ambulation). However, radial access requires a longer learning curve to develop technical skills, and the data on radial artery graft for coronary artery bypass graft after radial access remain insufficient. Further, recent clinical trials have shown conflicts regarding whether radial access is associated with lower mortality in patients with ST-elevation myocardial infarction. Despite these recent investigations, it is still debated whether there are benefits associated with radial access over femoral access for PCI. In this review, we will evaluate radial access compared with femoral access for PCI on clinical outcomes and further discuss the usefulness of radial access.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This study sought to present a novel computer model for fast computation of myocardial fractional flow reserve (FFR) and to evaluate it in patients with intermediate coronary stenoses.
FFR is an ...indispensable tool to identify individual coronary stenoses causing ischemia. Calculation of FFR from x-ray angiographic data may increase the utility of FFR assessment.
Consecutive patients with intermediate coronary stenoses undergoing pressure wire-based FFR measurements were analyzed by a core laboratory. Three-dimensional quantitative coronary angiography (QCA) was performed and the mean volumetric flow rate at hyperemia was calculated using TIMI (Thrombolysis In Myocardial Infarction) frame count combined with 3-dimensional QCA. Computational fluid dynamics was applied subsequently with a novel strategy for the computation of FFR. Diagnostic performance of the computed FFR (FFRQCA) was assessed using wire-based FFR as reference standard.
Computation of FFRQCA was performed on 77 vessels in 68 patients. Average diameter stenosis was 46.6 ± 7.3%. FFRQCA correlated well with FFR (r = 0.81, p < 0.001), with a mean difference of 0.00 ± 0.06 (p = 0.541). Applying the FFR cutoff value of ≤0.8 to FFRQCA resulted in 18 true positives, 50 true negatives, 4 false positives, and 5 false negatives. The area under the receiver-operating characteristic curve was 0.93 for FFRQCA, 0.73 for minimum lumen area, and 0.65 for percent diameter stenosis.
Computation of FFRQCA is a novel method that allows the assessment of the functional significance of intermediate stenosis. It may emerge as a safe, efficient, and cost-reducing tool for evaluation of coronary stenosis severity during diagnostic angiography.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Coronary artery calcium scanning (CAC) has emerged as the most robust predictor of coronary events in the asymptomatic primary prevention population, particularly in the intermediate-risk cohort. ...Every study has demonstrated its superiority to risk factor-based paradigms, e.g., the Framingham Risk Score, with outcome-based net reclassification indexes ranging from 52.0% to 65.6% in the intermediate-risk, 34.0% to 35.8% in the high-risk, and 11.6% to 15.0% in the low-risk cohorts. CAC improves medication and lifestyle adherence and is cost-effective in specified populations, with the ability to effectively stratify the number needed to treat and scan for different therapeutic strategies and patient cohorts. Data have emerged clearly demonstrating the worse prognosis associated with increasing CAC on serial scans, suggesting a potential role for evaluating residual risk and treatment success or failure. CAC is also strongly associated with the development of stroke and congestive heart failure.
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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 previous coronary artery bypass grafting often require invasive coronary angiography (ICA). However, for these patients, the procedure is technically more challenging and has a higher ...risk of complications. Observational studies suggest that computed tomography cardiac angiography (CTCA) may facilitate ICA in this group, but this has not been tested in a randomized controlled trial.
This study was a single-center, open-label randomized controlled trial assessing the benefit of adjunctive CTCA in patients with previous coronary artery bypass grafting referred for ICA. Patients were randomized 1:1 to undergo CTCA before ICA or ICA alone. The co-primary end points were procedural duration of the ICA (defined as the interval between local anesthesia administration for obtaining vascular access and removal of the last catheter), patient satisfaction after ICA using a validated questionnaire, and the incidence of contrast-induced nephropathy. Linear regression was used for procedural duration and patient satisfaction score; contrast-induced nephropathy was analyzed using logistic regression. We applied the Bonferroni correction, with
<0.017 considered significant and 98.33% CIs presented. Secondary end points included incidence of procedural complications and 1-year major adverse cardiac events.
Over 3 years, 688 patients were randomized with a median follow-up of 1.0 years. The mean age was 69.8±10.4 years, 108 (15.7%) were women, 402 (58.4%) were White, and there was a high burden of comorbidity (85.3% hypertension and 53.8% diabetes). The median time from coronary artery bypass grafting to angiography was 12.0 years, and there were a median of 3 (interquartile range, 2 to 3) grafts per participant. Procedure duration of the ICA was significantly shorter in the CTCA+ICA group (CTCA+ICA, 18.6±9.5 minutes versus ICA alone, 39.5±16.9 minutes 98.33% CI, -23.5 to -18.4;
<0.001), alongside improved mean ICA satisfaction scores (1=very good to 5=very poor; -1.1 difference 98.33% CI, -1.2 to -0.9;
<0.001), and reduced incidence of contrast-induced nephropathy (3.4% versus 27.9%; odds ratio, 0.09 98.33% CI, 0.04-0.2;
<0.001). Procedural complications (2.3% versus 10.8%; odds ratio, 0.2 95% CI, 0.1-0.4;
<0.001) and 1-year major adverse cardiac events (16.0% versus 29.4%; hazard ratio, 0.4 95% CI, 0.3-0.6;
<0.001) were also lower in the CTCA+ICA group.
For patients with previous coronary artery bypass grafting, CTCA before ICA leads to reductions in procedure time and contrast-induced nephropathy, with improved patient satisfaction. CTCA before ICA should be considered in this group of patients.
URL: https://www.
gov; Unique identifier: NCT03736018.
Accurately segmenting contrast-filled vessels from X-ray coronary angiography (XCA) image sequence is an essential step for the diagnosis and therapy of coronary artery disease. However, developing ...automatic vessel segmentation is particularly challenging due to the overlapping structures, low contrast and the presence of complex and dynamic background artifacts in XCA images. This paper develops a novel encoder–decoder deep network architecture which exploits the several contextual frames of 2D+t sequential images in a sliding window centered at current frame to segment 2D vessel masks from the current frame. The architecture is equipped with temporal–spatial feature extraction in encoder stage, feature fusion in skip connection layers and channel attention mechanism in decoder stage. In the encoder stage, a series of 3D convolutional layers are employed to hierarchically extract temporal–spatial features. Skip connection layers subsequently fuse the temporal–spatial feature maps and deliver them to the corresponding decoder stages. To efficiently discriminate vessel features from the complex and noisy backgrounds in the XCA images, the decoder stage effectively utilizes channel attention blocks to refine the intermediate feature maps from skip connection layers for subsequently decoding the refined features in 2D ways to produce the segmented vessel masks. Furthermore, Dice loss function is implemented to train the proposed deep network in order to tackle the class imbalance problem in the XCA data due to the wide distribution of complex background artifacts. Extensive experiments by comparing our method with other state-of-the-art algorithms demonstrate the proposed method’s superior performance over other methods in terms of the quantitative metrics and visual validation. To facilitate the reproductive research in XCA community, we publicly release our dataset and source codes at https://github.com/Binjie-Qin/SVS-net.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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