To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD).
Between April ...2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6 ± 8.7 vs. 6.1 ± 9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (€369 vs. €440; P < 0.0001).
For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing. Incorporating the calcium scan into the diagnostic workup was safe and lowered diagnostic expenses and radiation exposure.
Objective
To determine the potential impact of on-site CT-derived fractional flow reserve (CT-FFR) on the diagnostic efficiency and effectiveness of coronary CT angiography (CCTA) in patients with ...obstructive coronary artery disease (CAD) on CCTA.
Methods
This observational cohort study included patients with suspected CAD who had been randomized to cardiac CT in the CRESCENT I and II trials. On-site CT-FFR was blindly performed in all patients with at least one ≥ 50% stenosis on CCTA and no exclusion criteria for CT-FFR. We retrospectively assessed the effect of adding CT-FFR to the CT protocol in patients with a stenosis ≥ 50% on CCTA in terms of diagnostic effectiveness, i.e., the number of additional tests required to determine the final diagnosis, reclassification of the initial management strategy, and invasive coronary angiography (ICA) efficiency, i.e., ICA rate without ≥ 50% CAD.
Results
Fifty-three patients out of the 372 patients (14%) had at least one ≥ 50% stenosis on CCTA of whom 42/53 patients (79%) had no exclusion criteria for CT-FFR. CT-FFR showed a hemodynamically significant stenosis (≤ 0.80) in 27/53 patients (51%). The availability of CT-FFR would have reduced the number of patients requiring additional testing by 57%-points compared with CCTA alone (37/53 vs. 7/53,
p
< 0.001). The initial management strategy would have changed for 30 patients (57%,
p
< 0.001). Reserving ICA for patients with a CT-FFR ≤ 0.80 would have reduced the number of ICA following CCTA by 13%-points (
p
= 0.016).
Conclusion
Implementation of on-site CT-FFR may change management and improve diagnostic efficiency and effectiveness in patients with obstructive CAD on CCTA.
Key Points
• The availability of on-site CT-FFR in the diagnostic evaluation of patients with obstructive CAD on CCTA would have significantly reduced the number of patients requiring additional testing compared with CCTA alone.
• The implementation of on-site CT-FFR would have changed the initial management strategy significantly in the patients with obstructive CAD on CCTA.
• Restricting ICA to patients with a positive CT-FFR would have significantly reduced the ICA rate in patients with obstructive CAD on CCTA.
Introduction
The finding of left atria diverticula (LAD) on cardiac computed tomography images obtained from patients with atrial fibrillation (AF) referred for pulmonary vein isolation is not ...uncommon. Prior studies reporting on LAD do not always provide definitions of LAD resulting in confusion with other anatomical structures such as left atrial accessory appendages (LAAA) and atrial aneurysms. The aim of this review is to identify an accurate definition of LAD and to describe distinctive properties between LAD and other left atrial structures, such as LAAA and aneurysms. Also, the relation between LAD and development of atrial tachyarrhythmias is discussed.
Methods
PubMed was searched for studies reporting on atrial aneurysms, left atrial diverticula, left atrial accessory appendages and atrial congenital aneurysms, resulting in 36 papers.
Results
LAD can be distinguished from LAAA by taking into account embryologic origins of the left atrium and their locations, resulting in the following definitions: (a) LAAA are contractile, trabeculated structures with circumscriptive ostia and narrow necks, originating from the primitive atria, (b) LAD are contractile, sac like structures with either smooth or trabeculated inner surfaces, circumscriptive ostia, narrow necks, and variable morphologies, originating from the embryologic common pulmonary vein, that incorporates into the LA, and (c) atrial aneurysms are non‐contractile structures with wide necks and sac like bodies. There are no differences in prevalences of LAD between patients with sinus rhythm and AF.
Conclusion
The pathophysiology of LAD is not yet fully understood. It is unlikely, that LAD are related to the development of atrial tachycardia's and AF by either being a source of ectopic activity or being part of an arrhythmogenic substrate. No differences in LAD prevalences between patients with sinus rhythm and AF have been found. Thus, it is unlikely that LAD could potentially be wolves in sheep's clothing.
Objectives
The addition of CT-derived fractional flow reserve (FFR-CT) increases the diagnostic accuracy of coronary CT angiography (CCTA). We assessed the impact of FFR-CT in routine clinical ...practice on clinical decision-making and patient prognosis in patients suspected of stable coronary artery disease (CAD).
Methods
This retrospective, single-center study compared a cohort that received CCTA with FFR-CT to a historical cohort that received CCTA before FFR-CT was available. We assessed the clinical management decisions after FFR-CT and CCTA and the rate of major adverse cardiac events (MACEs) during the 1-year follow-up using chi-square tests for independence. Kaplan–Meier curves were used to visualize the occurrence of safety outcomes over time.
Results
A total of 360 patients at low to intermediate risk of CAD were included, 224 in the CCTA only group, and 136 in the FFR-CT group. During follow-up, 13 MACE occurred in 12 patients, 9 (4.0%) in the CCTA group, and three (2.2%) in the FFR-CT group. Clinical management decisions differed significantly between both groups. After CCTA, 60 patients (26.5%) received optimal medical therapy (OMT) only, 115 (51.3%) invasive coronary angiography (ICA), and 49 (21.9%) single positron emission CT (SPECT). After FFR-CT, 106 patients (77.9%) received OMT only, 27 (19.9%) ICA, and three (2.2%) SPECT (
p
< 0.001 for all three options). The revascularization rate after ICA was similar between groups (
p
= 0.15). However, patients in the CCTA group more often underwent revascularization (
p
= 0.007).
Conclusion
Addition of FFR-CT to CCTA led to a reduction in (invasive) diagnostic testing and less revascularizations without observed difference in outcomes after 1 year.
Key Points
•
Previous studies have shown that computed tomography–derived fractional flow reserve improves the accuracy of coronary computed tomography angiography without changes in acquisition protocols.
•
This study shows that use of computed tomography-derived fractional flow reserve as gatekeeper to invasive coronary angiography in patients suspected of stable coronary artery disease leads to less invasive testing and revascularization without observed difference in outcomes after 1 year.
•
This could lead to a significant reduction in costs, complications and (retrospectively unnecessary) usage of diagnostic testing capacity, and a significant increase in patient satisfaction.
Purpose
Metabolic syndrome in patients with morbid obesity causes a higher cardiovascular morbidity, eventually leading to left ventricular hypertrophy and decreased left ventricular ejection ...fraction (LVEF). Roux-en-Y gastric bypass (RYGB) is considered the gold standard modality for treatment of morbid obesity and might even lead to improved cardiac function. Our objective is to investigate whether cardiac function in patients with morbid obesity improves after RYGB.
Materials and Methods
In this single center pilot study, 15 patients with an uneventful cardiac history who underwent RYGB were included from May 2015 to March 2016. Cardiac function was measured by cardiac magnetic resonance imaging (CMRI), performed preoperatively and 3, 6, and 12 months postoperative. LVEF and myocardial mass and cardiac output were measured.
Results
A total of 13 patients without decreased LVEF preoperative completed follow-up (mean age 37, 48.0 ± 8.8). There was a significant decrease of cardiac output 12 months postoperative (8.3 ± 1.8 preoperative vs. 6.8 ± 1.8 after 12 months,
P
= 0.001). Average myocardial mass declined by 15.2% (
P
< 0.001). After correction for body surface area (BSA), this appeared to be non-significant (
P
= 0.36). There was a significant improvement of LVEF/BSA at 6 and 12 months postoperative (26.2 ± 4.1 preoperative vs. 28.4 ± 3.4 and 29.2 ± 3.6 respectively, both
P
= 0.002). Additionally, there was a significant improvement of stroke volume/BSA 12 months after surgery (45.8 ± 8.0 vs. 51.9 ± 10.7,
P
= 0.033).
Conclusion
RYGB in patients with morbid obesity with uneventful history of cardiac disease leads to improvement of cardiac function.
Primary carnitine deficiency is a rare autosomal recessive disease associated with acute hypoketotic hypoglycaemia, cardiomyopathy and sudden cardiac death. Effective treatment with carnitine ...supplementation is available. An 18 months old boy, who presented with cardiomyopathy was diagnosed with primary carnitine deficiency, and carnitine supplementation resulted in a full recovery. At age 13 years, he discontinued his medication and at 20 years, he discontinued clinical monitoring. Nine years later, age 29, he presented with heart failure and atrial fibrillation and was admitted to an intensive care unit, where he was treated with furosemide, enoximone and intravenous carnitine supplementation, this lead to improved cardiac function within 2 weeks, and with continued oral carnitine supplements, his left ventricular ejection fraction normalised. The last 8 years were uneventful and he continued to attend his regular follow‐up visits at a specialised metabolic outpatient clinic. We report recurrent reversible severe heart failure in a patient with primary carnitine deficiency; it was directly related to non‐compliance to carnitine supplementation (and monitoring). This case report emphasises first, the importance of continued monitoring of metabolic disease patients, second, the potential reversibility of cardiomyopathy in an adult patient, and third, the potential risks in the period of transition from the paediatric to adult care. This is an age where young adults desire to be healthy and ignore the need for ongoing medical treatment, even as simple as oral suppletion. Before they reach this age, adequate disease insight and self‐management of the disease should be promoted.
Background
Carotid intima-media thickness (CIMT) is increasingly used as a prognostic indicator for early atherosclerosis and the development of cardiovascular disease. The objective of this study is ...to assess the exact effects of bariatric surgery on CIMT reduction in different age groups.
Methods
CIMT was measured just proximal to the bifurcation of the carotid artery in 166 patients with mean body mass index of 43.4 kg/m
2
before and at 6 and 12 months after bariatric surgery. Preoperative CIMT and Framingham Risk Score (FRS) were compared to measurements at 6 and 12 months, postoperatively. Impact of age on CIMT change and cardiovascular risk reduction was analyzed.
Results
Median follow-up was 12 months; 12% were lost to follow-up. Mean CIMT values at 12 months after bariatric surgery were significantly lower compared to baseline (0.619 vs. 0.587 mm,
p
= 0.005 in women and 0.675 vs. 0.622 mm,
p
= 0.037 in men, respectively), and these effects were statistically significant in all age groups. The mean reduction of CIMT for patients < 50 years at 12 months was 0.043 mm (− 7.0%), while CIMT was reduced with 0.013 mm for patients ≥ 50 years (− 1.9%,
p
= 0.022). At 12 months after bariatric surgery, FRS had decreased with 52% in patients < 50 years as compared with 35% in patients ≥ 50 years (
p
= 0.025).
Conclusions
Bariatric surgery resulted in a significant CIMT decrease in patients with morbid obesity in all evaluated age categories. These beneficial effects of bariatric surgery were more pronounced in younger patients, while cardiovascular risk reduction by bariatric surgery appeared inferior in patients of 50 years and older.
Companies that provide charging infrastructure for the electric vehicles of their employees, customers and their own company fleet should take into account that energy costs may increase not only due ...to higher energy consumption, but also due to possible new load peaks. Charging and energy management systems should ensure that these load peaks, and thus significant cost increases, are avoided. Assuming that bidirectional charging will be the norm for electric vehicles in the future, such a management system could also cause the vehicle batteries to provide power for a short time if necessary. This could additionally smooth peak loads of the company resulting from their production, for example, and further reduce electricity costs. A possible procedure, which requires little information and no predictions, is presented in this paper. Based on simulation results, it is shown that it can be used to both avoid and smooth load peaks, and that a medium-sized company can save several thousand euros annually as a result.
This study sought to assess the effectiveness, efficiency, and safety of a tiered, comprehensive cardiac computed tomography (CT) protocol in comparison with functional testing.
Although CT ...angiography accurately rules out coronary artery disease (CAD), incorporation of CT myocardial perfusion imaging as part of a tiered diagnostic approach could improve the clinical value and efficiency of cardiac CT in the diagnostic work-up of patients with angina pectoris.
Between July 2013 and November 2015, 268 patients (mean age 58 years; 49% female) with stable angina (mean pre-test probability 54%) were prospectively randomized between cardiac CT and standard guideline-directed functional testing (95% exercise electrocardiography). The tiered cardiac CT protocol included a calcium scan, followed by CT angiography if calcium was detected. Patients with ≥50% stenosis on CT angiography underwent CT myocardial perfusion imaging.
By 6 months, the primary endpoint, the rate of invasive coronary angiograms without a European Society of Cardiology class I indication for revascularization, was lower in the CT group than in the functional testing group (2 of 130 1.5% vs. 10 of 138 7.2%; p = 0.035), whereas the proportion of invasive angiograms with a revascularization indication was higher (88% vs. 50%; p = 0.017). The median duration until the final diagnosis was 0 (0 of 0) days in the CT group and 0 (0 of 17) in the functional testing group (p < 0.001). Overall, 13% of patients randomized to CT required further testing, compared with 37% in the functional testing group (p < 0.001). The adverse event rate was similar (3% vs. 3%; p = 1.000), although the median cumulative radiation dose was higher for the CT group (3.1 mSv interquartile range: 1.6 to 7.8 vs. 0 mSv interquartile range: 0.0 to 7.1; p < 0.001).
In patients with suspected stable CAD, a tiered cardiac CT protocol with dynamic perfusion imaging offers a fast and efficient alternative to functional testing. (Comprehensive Cardiac CT Versus Exercise Testing in Suspected Coronary Artery Disease 2 CRESCENT2; NCT02291484).
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