Coronary stenosis severity is both a powerful and a still debated predictor of prognosis in coronary artery disease. Coronary computed tomographic angiography (CCTA) has emerged as a noninvasive ...technique that enables anatomic visualization of coronary artery disease (CAD). CCTA with newer applications, plaque characterization and physiologic/functional evaluation, allows a comprehensive diagnostic and prognostic assessment of otherwise low-intermediate subjects for primary prevention. CCTA measures the overall plaque burden, differentiates plaque subtypes, and identifies high-risk plaque with good reproducibility. Research in this field may also advance towards an era of personalized risk prediction and individualized medical therapy. It has been demonstrated that statins may delay plaque progression and change some plaque features. The potential effects on plaque modifications induced by other medical therapies have also been investigated. Although it is not currently possible to recommend routinely serial scans to monitor the therapeutic efficacy of medical interventions, the plaque modulation, as a part of risk modification, appears a feasible strategy. In this review we summarize the current evidence regarding vulnerable plaque and effects of lipid lowering therapy on morphological features of CAD. We also discuss the potential ability of CCTA to characterize coronary atherosclerosis, stratify prognosis of asymptomatic subjects, and guide medical therapy.
Abstract Cardiac resynchronization therapy (CRT) is a successful strategy for heart failure (HF) patients. The pre-requisite for the response is the evidence of electrical dyssynchrony on the surface ...electrocardiogram usually as left bundle branch block (LBBB). Non response to CRT is a significant problem in clinical practice. Patient selection, inadequate delivery and sub-ottimal left ventricle lead position may be important causes. In a effort to improve CRT response multimodality imaging (especially echocardiography, computed tomography and cardiac magnetic resonance) could play a decisive role and extensive literature has been published on the matter. However, we are so far from routinary use in clinical practice. Electrocardiography (with respect of left ventricle capture and QRS narrowing) may represent a simple and low cost approach for early prediction of potential non-responder, with immediate practical implications. This brief review covers the current reccomendations for CRT in HF patients with particular attention to the potential benefits of multimodality imaging and electrocardiography in improving response rate.
The aim of the study was to compare three widely used algorithms for stratification of the global cardiovascular risk (GCVR): the Framingham Heart Study (FHS) score, the European systemic coronary ...risk estimation (SCORE) and the Italian 'Progetto Cuore' (heart project) score. It was also investigated how preclinical carotid atherosclerosis (pre-ATS) might influence the incidence and improve the risk prediction of cerebrovascular and cardiovascular events.
Subjects (n = 358) without previous history of cardiovascular disease (CVD) were recruited and the GCVR was calculated for each patient. An ultrasound evaluation of the carotid arteries was also performed.
According to SCORE, the recruited population had globally a low risk of cardiovascular mortality and the risk equation estimated a GCVR of 2% in spite of the in spite of the observed rate of 0.8% (95% CI -0.001 to 0.02) of fatal events. The FHS and the 'Progetto Cuore' risk equations, regarding a 10-year risk of fatal and nonfatal events, predicted a low GCVR of 31 and 30%, an intermediate risk of 64 and 66%, and a high risk of 5 and 4% of the population respectively. They also estimated a general GCVR of 6.9 and 6.4% respectively versus an observed event rate 27.7 (95% CI 23.0 to 32.0). The discriminative power, calculated with the area under the receiving operator curve (AUROC), was 0.53 for SCORE, 0.54 for FHS and 0.55 for Progetto Cuore. Based on the ultrasound evaluation of carotid arteries, a first clinical event at 10-year follow-up was reported in 3% of subjects with normal ultrasound examination, 32% with intima-media thickening (IMT) and 62% with asymptomatic carotid plaque (ACP).
The present study has evaluated for the first time the prediction of GCVR in an asymptomatic population, comparing three different risk scores. Carotid pre-ATS was related to the major cardiovascular risk factors (RFs) and was independently associated with a major incidence of cerebro- and cardiovascular events, therefore enhancing the predictive value of the three different risk scores.
Abstract Aim To evaluate if the intima-media thickening (IMT) and asymptomatic carotid plaque (ACP), as expression of carotid preclinical atherosclerosis (pre-ATS), can provide further information on ...the global cardiovascular risk (GCVR). Methods We studied 454 asymptomatic subjects, with a cluster of risk factors (RF), and evaluated the incidence of a first cardiovascular (CV) event in a five-year follow-up. The subjects at admission were subdivided in three groups of risk. Results Events occurred in 38% of subjects at high risk, in 13% and 6% of subjects at intermediate and low risk ( p < 0.003). Among evaluated parameters, carotid pre-ATS was a predictive marker of CV events (OR 2.7, 95% IC 1.4–5.1, p < 0.0024). In subjects with GCVR <20% the prevalence of events was 8% for normal carotid ultrasound findings, 13% for increased IMT and 15% for ACP. Conclusions In primary prevention, the IMT measurement can give further information for a better stratification of GCVR. The pre-ATS of carotid arteries should be considered a strong predictor of future CV events and should suggest a more aggressive treatment of RF.
In the last decades, a trend towards a worldwide aging has been reported and diseases which are common in the elderly people would have important implications in clinical practice. Aortic stenosis ...（AS） is perhaps the most common and most often cause of sudden death among valvular heart diseases. Its prevalence is low among adults aged 〈 60 years, but increases to almost 10% in adults ≥ 80 years.2 Since the degenerative calcific disease represents the lead- ing cause of AS in developed countries, the improved understanding on its pathogenesis （atherosclerotic processes and/or skeleton key） may offer potentially new targets for preventing and inhibiting AS development and progres- sion.3 Patients with AS are generally asymptomatic for a prolonged period and the development of symptoms is a critical point in the natural history. Indeed, the prognosis changes dramatically with the onset of symptoms of angina,
Purpose of Review
The purpose of the present paper is to analytically review the diagnostic and prognostic role of CMR in ST-segment elevation myocardial infarction (STEMI) survivors. Percutaneous ...coronary intervention (PCI) is the treatment of choice in patients STEMI. However, risk of future events remains substantial. Assessment of the extent of myocardial infarction (MI), cardiac function and ventricular remodelling has become the focus of recent studies. Electrocardiography, angiography and echocardiography parameters, as well as risk scores, lack sensitivity and reproducibility in predicting future cardiovascular events. A major advantage of cardiac magnetic resonance imaging (CMR) is that it provides myocardial tissue characterization.
Recent Findings
CMR is able to quantify both reversible and irreversible myocardial injury and correlates with future events.
Summary
This review will illustrate how microvascular function indices (myocardial salvage index, presence and amount of microvascular obstruction and intramyocardial haemorrhage) detectable by CMR add prognostic information and could impact on future strategies to improve outcomes in revascularized patients.
Takotsubo cardiomyopathy (TC) is characterized by transient systolic dysfunction of the apical and middle segments of the left ventricle, accompanied by electrocardiographic abnormalities and mild ...elevation of cardiac biomarker levels in the absence of obstructive coronary artery disease. The following case is of a woman suffering from chronic emotional stress with a very early recurrence. An acute trigger event was not detectable in both cases. It is possible to suppose that, in predisposed subjects, chronic stress by increasing sympathetic activity may be considered not only a trigger for TC, but also a negative prognostic factor for early recurrence.
In the treatment of stable coronary artery disease (CAD) the identification of patients who may gain the highest benefit from further invasive treatments is of pivotal importance for the healthcare ...system. In this setting, it has been established that an ischemia-guided revascularization strategy yields improved clinical outcomes in a cost-effective fashion compared with anatomy-guided revascularization alone. Invasive fractional flow reserve (FFR) is considered the gold standard, especially in the intermediate-range atherosclerotic lesions, for assessing lesion specific ischemia at the time of invasive coronary angiography and has now become the standard of reference for studies assessing the diagnostic performance of the various non-invasive stress tests. Coronary computed tomography angiography (cCTA) is an increasingly utilized non-invasive test that enables direct anatomical visualization of CAD in the epicardial coronary arteries with excellent sensitivity and negative predictive value. However, cCTA alone has poor specificity with FFR. With advances in computational fluid dynamics, it is possible to derive FFR from cCTA datasets improving its positive predictive value and specificity. The aim of this review is to summarize the technical aspects of FFR-CT, clinical evidence and limitations behind the novel technology, with a special focus on the recent PLATFORM Trial analyzing the effectiveness, clinical outcomes and resource utilization of FFR-CT. Finally, the future perspective of FFR-CT will be presented.
Cardiac magnetic resonance (CMR) findings suggesting a suspected left-dominant arrhythmogenic cardiomyopathy (LDAC) may be difficult to distinguish from those related to previous myocarditis; ...however, especially in patients with ventricular arrhythmias (VA) with ECG morphology consistent with a left ventricle (LV) origin differential diagnosis is fundamental. Aim of the study was to identify potential imaging features at CMR specific for LDAC diagnosis. Between January 2011 and December 2019, we enrolled 15 consecutive stable patients with a recent diagnosis of significant VA and ECG morphology consistent with a LV origin, detection of potential LV arrhythmic substrate at CMR and undergoing a clinically-indicated LV endomyocardial biopsy showing tissue abnormalities consistent with the diagnosis of LDAC. From the same CMR-endomyocardial biopsy registry, a second group of 30 consecutive patients who underwent CMR and biopsy with a histological diagnosis of previous myocarditis were identified. (1) Subepicardial LGE at the level of the posterolateral wall of the LV was detected in 13 cases of LDAC vs. 21 cases of myocarditis; (2) fat infiltration, and particularly subepicardial posterolateral fat infiltration, was found in almost all LDAC patients vs. one myocarditis only (p < 0.01). (3) No differences in other CMR findings or in any clinical or echocardiographic parameters were found between patients with a biopsy consistent with LDAC vs. myocarditis. In patients with significant VA and ECG morphology consistent with a LV origin, the presence of morpho-functional involvement of the subepicardial layer of LV posterolateral wall at CMR (LGE, fat infiltration, wall dyskinesis) supports LDAC diagnosis.
Abstract Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of ...the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery. Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms. In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.
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