Abstract Appropriate use criteria (AUC) for single-photon emission computed tomography myocardial perfusion images (SPECT-MPI) were developed to address the growth of cardiac imaging studies. Long ...term prognostic value of AUC in SPECT-MPI has not been tested in existing cohorts. We sought to determine the long term prognostic value of MPI classified as appropriate. AUC was evaluated in a prospectively designed cohort of patients who underwent clinically indicated MPI. MPI studies were classified based on 2009 AUC for SPECT-MPI. Data regarding downstream coronary angiography (cath), revascularization and all-cause mortality, cardiac death and nonfatal myocardial infarction (MI) were collected from national registries. Among n=1129 MPI scans that received an appropriate grading, 148 all-cause deaths, 109 MI, 58 cardiac deaths, 152 caths, 113 revascularization procedures occurred over a mean follow-up period of 5.4 ± 1.2 years (0.9% cardiac death rate per year, 1.8% MI rate per year). Most of the scans were low-risk normal MPI scans (summed stress score ≤3) (74.1%). An abnormal scan was associated with higher rates of MI (19.5% vs 6.2%, HR 1.72, p=0.017) and cardiac death (13.4% vs 2.3%, HR 2.12, p=0.016). In conclusion, MPI scans classified as appropriate have long-term prognostic value, despite a high proportion of low risk scans. This provides support for clinicians to consider the use of appropriate grading in addition to MPI scan results in patient management.
Background:Cardiac size measurements require indexing to body size. Allometric indexing has been investigated in Caucasian populations but a range of different values for the so-called allometric ...power exponent (b) have been proposed, with uncertainty as to whether allometry offers clinical utility above body surface area (BSA)-based indexing. We derived optimal values forbin normal echocardiograms and validated them externally in cardiac patients.Methods and Results:Values forbwere derived in healthy adult Chinese males (n=1,541), with optimalbfor left ventricular mass (LVM) of 1.66 (95% confidence interval 1.41–1.92). LV hypertrophy (LVH) defined as indexed LVM >75 g/m1.66was associated with adverse outcomes in an external validation cohort (n=738) of patients with acute coronary syndrome (odds ratio for reinfarction: 2.4 (1.1–5.4)). In contrast, LVH defined by BSA-based indexing or allometry using exponent 2.7 exhibited no significant association with outcomes (P=NS for both). Cardiac longitudinal function also varied with body size: septal and RV free wall s’, TAPSE and lateral e’ all scaled allometrically (b=0.3–0.9).Conclusions:An optimalbof 1.66 for LVM in healthy Chinese was found to validate well, with superior clinical utility both to that of BSA-based indexing and tob=2.7. The effect of allometric indexing of cardiac function requires further study.
It is unclear whether universal access to primary percutaneous coronary intervention (pPCI) may reduce sex differences in 1-year rehospitalization for heart failure (HF) and myocardial infarction ...(MI) after ST-elevation myocardial infarction (STEMI). We studied 7,597 consecutive STEMI patients (13.8% women, n = 1,045) who underwent pPCI from January 2007 to December 2013. Cox regression models adjusted for competing risk from death were used to assess sex differences in rehospitalization for HF and MI within 1 year from discharge. Compared with men, women were older (median age 67.6 vs 56.0 years, p < 0.001) with higher prevalence of co-morbidities and multivessel disease. Women had longer median door-to-balloon time (76 vs 66 minutes, p < 0.001) and were less likely to receive drug-eluting stents (19.5% vs 24.1%, p = 0.001). Of the medications prescribed at discharge, fewer women received aspirin (95.8% vs 97.6%, p = 0.002) and P2Y12 antagonists (97.6% vs 98.5%, p = 0.039), but there were no significant sex differences in other discharge medications. After adjusting for differences in baseline characteristics and treatment, sex differences in risk of rehospitalization for HF attenuated (hazard ratio HR 1.05, 95% confidence interval CI 0.79 to 1.40), but persisted for MI (HR 1.68, 95% CI 1.22 to 2.33), with greater disparity in patients aged ≥60 years (HR 1.83, 95% CI 1.18 to 2.85) than those aged <60 years (HR 1.45, 95% CI 0.84 to 2.50). In conclusion, in a setting of universal access to pPCI, the adjusted risk of 1-year rehospitalization for HF was similar in both sexes, but women had significantly higher adjusted risk of 1-year rehospitalization for MI, especially older women.
Abstract Background/objectives This study aims to examine iliofemoral anatomy and predictors of vessel size and tortuosity in Asian patients as transfemoral transcatheter aortic valve implantation ...(TAVI) may be limited by the smaller Asian physique. Methods Characteristics and vessel dimensions of 549 patients undergoing ultrasonography were reviewed. The minimal luminal diameter (MLD) along the iliofemoral vasculature of each side was identified and the larger of the two sides was used to determine suitability for transfemoral TAVI. Results The mean age was 66 ± 11 years (68% males). Mean iliac MLD was 7.6 ± 1.7 mm, females smaller than males (7.2 ± 1.7 vs 7.8 ± 1.7, p < 0.001). Mean iliac MLD decreased with age: 7.9 ± 1.7 mm, 7.4 ± 1.9 mm and 7.3 ± 1.6 mm for ages < 70 years, 70–79 years and ≥ 80 years respectively (p = 0.038). Mean femoral MLD was 7.0 ± 1.7 mm, females smaller than males (6.3 ± 1.5 mm vs 7.3 ± 1.8 mm, p < 0.001). Females were more likely than males to have iliac and femoral MLD < 6 mm (20% vs 12%, p = 0.019 and 34% vs 21%, p = 0.001). Independent predictors of smaller iliofemoral dimensions were female gender, lower body surface area, diabetes mellitus, dyslipidemia and smoking history. Significant iliac tortuosity was present in 11.8%, more frequent in males than females (15% vs 6%, p = 0.005), and in those with logistic EuroSCORE ≥ 15 than < 15 (27% vs 10%, p = 0.001). Conclusions This study establishes the mean iliac and femoral artery diameters in a cohort of relatively young Asian patients. Age and female gender were associated with smaller vessel dimension and several independent predictors of smaller vasculature and tortuosity were identified. These results have implications for TF TAVI in Asia.
Background Most pretest probability (PTP) tools for obstructive coronary artery disease (CAD) were Western ‐developed. The most appropriate PTP models and the contribution of coronary artery calcium ...score (CACS) in Asian populations remain unknown. In a mixed Asian cohort, we compare 5 PTP models: local assessment of the heart (LAH), CAD Consortium (CAD2), risk factor‐weighted clinical likelihood, the American Heart Association/American College of Cardiology and the European Society of Cardiology PTP and 3 extended versions of these models that incorporated CACS: LAH (CACS) , CAD2 (CACS) , and the CACS‐clinical likelihood. Methods and Results The study cohort included 771 patients referred for stable chest pain. Obstructive CAD prevalence was 27.5%. Calibration, area under the receiver‐operating characteristic curves (AUC) and net reclassification index were evaluated. LAH clinical had the best calibration (χ 2 5.8; P =0.12). For CACS models, LAH (CACS) showed least deviation between observed and expected cases (χ 2 37.5; P <0.001). There was no difference in AUCs between the LAH clinical (AUC, 0.73 95% CI, 0.69–0.77), CAD2 clinical (AUC, 0.72 95% CI, 0.68–0.76), risk factor‐weighted clinical likelihood (AUC, 0.73 95% CI: 0.69–0.76) and European Society of Cardiology PTP (AUC, 0.71 95% CI, 0.67–0.75). CACS improved discrimination and reclassification of the LAH (CACS) (AUC, 0.88; net reclassification index, 0.46), CAD2 (CACS) (AUC, 0.87; net reclassification index, 0.29) and CACS‐CL (AUC, 0.87; net reclassification index, 0.25). Conclusions In a mixed Asian cohort, Asian‐derived LAH models had similar discriminatory performance but better calibration and risk categorization for clinically relevant PTP cutoffs. Incorporating CACS improved discrimination and reclassification. These results support the use of population‐matched, CACS‐inclusive PTP tools for the prediction of obstructive CAD.
Background Warfarin remains an important anticoagulant in certain patient groups. Though primarily liver-metabolised, recent research suggests renal function influences warfarin dosing. This has yet ...to be explored in a Southeast Asian population. Objectives To investigate the impact of renal impairment and ethnicity on warfarin dosing in a multi-ethnic Asian population. Methods A retrospective cohort analysis on patients seen at the institution’s anticoagulation clinic (ACC) between 2010 and 2019 was conducted. Results Among 3610 eligible patients, 70.7% had no/ mild renal impairment (eGFR≥60 ml/min/1.73m2), 24.7% had moderate renal impairment (eGFR 30 to <60ml/min/1.73m2), and 4.5% had severe renal impairment (eGFR<30 ml/min/1.73m2). Patients with moderate renal impairment required a 19% lower maintenance warfarin dose (β = 0.81, 95% CI 0.79–0.84, p < .001), and those with severe renal impairment needed a 30% lower dose (β = 0.70, 95% CI 0.66–0.75, p < .001) compared to patients with normal kidney function. Ethnically, 84.4% were Chinese, 9.5% Malay, and 6.1% South Asian. Compared to Chinese, Malays required an 18% larger maintenance dose (β = 1.18, 95% CI 1.12–1.23, p < .001), and South Asians needed an 83% larger dose (β = 1.83, 95% CI 1.73–1.94, p < .001). Compared to patients with normal renal function of the same race, South Asians with impaired renal function required a 16% lower dose, while Malay and Chinese patients needed 21% and 23% lower doses, respectively. Conclusion In this large multi-ethnic Asian study, renal function and ethnicity significantly affected maintenance warfarin dosing. South Asian patients required larger doses but were less affected by renal impairment compared to Chinese and Malays.
BACKGROUND Electrocardiography (ECG) may be performed as part of preparticipation sports screening. Recommendations on screening of athletes to identify individuals with previously unrecognized ...cardiac disease are robust; however, data guiding the preparticipation screening of unselected populations are scarce. T wave inversion (TWI) on ECG may suggest an undiagnosed cardiomyopathy. This study aims to describe the prevalence of abnormal TWI in an unselected young male cohort and the outcomes of an echocardiography-guided approach to investigating these individuals for structural heart diseases, focusing on the yield for cardiomyopathies. METHODS AND RESULTS Consecutive young male individuals undergoing a national preparticipation cardiac screening program for 39 months were studied. All underwent resting supine 12-lead ECG. Those manifesting abnormal TWI, defined as negatively deflected T waves of at least 0.1 mV amplitude in any 2 contiguous leads, underwent echocardiography. A total of 69 714 male individuals with a mean age of 17.9±1.1 years were studied. Of the individuals, 562 (0.8%) displayed abnormal TWI. This was most frequently observed in the anterior territory and least so in the lateral territory. A total of 12 individuals (2.1%) were diagnosed with a cardiomyopathy. Cardiomyopathy diagnoses were significantly associated with deeper maximum TWI depth and the presence of abnormal TWI in the lateral territory, but not with abnormal TWI in the anterior and inferior territories. No individual presenting with TWI restricted to solely leads V
to V
, 2 inferior leads or both was diagnosed with a cardiomyopathy. CONCLUSIONS Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal TWI. Our findings may support decisions to prioritize echocardiography in these individuals.
The objective of this study is to compare the incremental prognostic and net risk reclassification value of exercise testing alone vs exercise myocardial perfusion imaging (MPI) for estimating the ...risk of death in patients with suspected and known coronary artery disease (CAD).
6702 patients with suspected CAD and 2008 with known CAD had treadmill exercise MPI and were followed for 2.5 ± 0.9 years for the occurrence of all-cause death. The estimation of risk of death and net reclassification improvement (NRI) were examined in three models. Model 1: clinical variables; Model 2: model 1+Duke Treadmill Score; and Model 3: model 2+ MPI variables. Risk estimates were categorized as <1%, 1-3%, and >3% risk of death per year.
In patients with suspected CAD, the global Chi-square for predicting risk of death increased significantly for Model 2 compared to Model 1 (74.78 vs 63.86 to (P = .001). However, adding MPI variables in Model 3 did not further improve predictive value (Chi-square 79.38, P = .10). In patients with suspected CAD risk, reclassification improved significantly in Model 2 over Model 1 (NRI = 0.12, 95% CI 0.02 to 0.22, P = .019), but not in Model 3 (NRI = 0.0009, 95% CI −0.072 to 0.070; P = .98). In contrast, in patients with known CAD Model 2 did not yield significant improvements for predicting risk and risk reclassification compared to Model 1. However, global Chi-square of Model 3 was significantly higher than that of Model 2 (30.03 vs 6.56, P < .0001) with associated significant reclassification improvement (NRI = 0.26 95% CI 0.067 to 0.46. P = .0084).
Risk reclassification by diagnostic testing is importantly influenced by baseline characteristics of patient cohorts. In patients with suspected CAD, NRI is predominately achieved by exercise variables, whereas in patients with known CAD, greatest NRI is obtained by MPI variables.
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