To determine diagnostic performance of non-invasive tests using invasive fractional flow reserve (FFR) as reference standard for coronary artery disease (CAD).
Medline, Embase, and citations of ...articles, guidelines, and reviews for studies were used to compare non-invasive tests with invasive FFR for suspected CAD published through March 2017.
Seventy-seven studies met inclusion criteria. The diagnostic test with the highest sensitivity to detect a functionally significant coronary lesion was coronary computed tomography (CT) angiography 88%(85%–90%), followed by FFR derived from coronary CT angiography (FFRCT) 85%(81%–88%), positron emission tomography (PET) 85%(82%–88%), stress cardiac magnetic resonance (stress CMR) 81%(79%–84%), stress myocardial CT perfusion combined with coronary CT angiography 79%(74%–83%), stress myocardial CT perfusion 77%(73%–80%), stress echocardiography (Echo) 72%(64%–78%) and stress single-photon emission computed tomography (SPECT) 64%(60%–68%). Specificity to rule out CAD was highest for stress myocardial CT perfusion added to coronary CT angiography 91%(88%–93%), stress CMR 91%(90%–93%), and PET 87%(86%–89%).
A negative coronary CT angiography has a higher test performance than other index tests to exclude clinically-important CAD. A positive stress myocardial CT perfusion added to coronary CT angiography, stress cardiac MR, and PET have a higher test performance to identify patients requiring invasive coronary artery evaluation.
•CTCA is an excellent tool to rule out obstructive CAD.•FFRCT or stress CTP improve the post-test likelihood of significant CAD.•PET, CMR, and CTCA combined with CTP showed the highest positive likelihood ratio.
Even if from a cultural level we have implemented substantial progress in terms of discrimination, in many countries gay people are still considered abnormal or deviant. This view still triggers ...stigmatization and labeling that affects how people, not just homosexuals, represent themselves and how they interact. This research examines the labeling processes suffered, and the role that they have played in homosexual identity construction, in particular with regard to homophobia. Based on semi-structured interviews, applied to homosexuals coming from the same Italian region, we have found that labeling on the part of friends and acquaintances has affected people’s lives, especially during adolescence. We also highlighted theories used by the interviewees on how to handle labeling, and where one can get ideas for improving interventions against discrimination to be implemented in educational contexts, especially with regard to the need to counter the internalization of homophobia.
Neisseria elongata (NE) is an aerobic Gram-negative organism that constitutes part of the commensal human normal oropharyngeal flora. Although previously considered not to be pathogenic, it has been ...recognized as an occasional cause of significant infections in humans. We report here the first case in Italy of infective endocarditis of a native prolapsing mitral valve in a patient with Marfan syndrome, caused by NE subspecies nitroreducens which has been rarely isolated from clinical specimens. The culprit organism has been confirmed by mass spectrometry directly from the positive blood culture, as previously reported. The amplified gene has been deposited in GenBank under accession number KT591873. In spite of the reported aggressive nature of NE, clinical remission was promptly obtained, there being no requirement for surgery.
Cardiac magnetic resonance (CMR) is a robust tool to evaluate left ventricular ejection fraction (LVEF), myocardial salvage index, microvascular obstruction, and myocardial hemorrhage in patients ...with ST-segment-elevation myocardial infarction. We evaluated the additional prognostic benefit of a CMR score over standard prognostic stratification with global registry of acute coronary events (GRACE) score and transthoracic echocardiography LVEF measurement.
Two hundred nine consecutive patients with ST-segment-elevation myocardial infarction (age, 61.4±11.4 years; 162 men) underwent transthoracic echocardiography and CMR after succesful primary percutaneous coronary intervention. Major adverse cardiac events (MACE) were assessed at a mean follow-up of 2.5±1.2 years. MACE occurred in 24 (12%) patients who at baseline showed higher GRACE risk score (
<0.01), lower LVEF with both transthoracic echocardiography and CMR, lower myocardial salvage index, and higher per-patient myocardial hemorrhage and microvascular obstruction prevalence and amount as compared with patients without MACE (
<0.01). The best cut-off values of transthoracic echocardiography-LVEF, CMR-LVEF, myocardial salvage index, and microvascular obstruction to predict MACE were 46.7%, 37.5%, 0.4, and 2.6% of left ventricular mass, respectively. Accordingly, a weighted CMR score, including the following 4 variables (CMR-LVEF, myocardial salvage index, microvascular obstruction, and myocardial hemorrhage), with a maximum of 17 points was calculated and included in the multivariable analysis showing that only CMR score (hazard ratio, 1.867 per SD increase 1.311-2.658;
<0.001) was independently associated with MACE with the highest net reclassification improvement as compared to GRACE score and transthoracic echocardiography-LVEF measurement.
CMR score provides incremental prognostic stratification as compared with GRACE score and transthoracic echocardiography-LVEF and may impact the management of patients with ST-segment-elevation myocardial infarction.
The difference (DeltaQTc) between the QTc of ischemic myocardium (maximum QTc in anterior leads) versus remote myocardium (minimum QTc in inferiorleads) over the first week, left ventricle ...enddiastolic (LVESVCMR) and endsystolic volume (LVESVCMR), numbers of myocardial segments with wall motion abnormalities (WMA index), left ventricle ejection fraction (EFCMR), and myocardial salvage index (MSI) were measured.
A new postprocessing algorithm named adaptive statistical iterative reconstruction (ASIR)-V has been recently introduced. The aim of this article was to analyze the impact of ASIR-V algorithm on ...signal, noise, and image quality of coronary computed tomography angiography.
Fifty consecutive patients underwent clinically indicated coronary computed tomography angiography (Revolution CT; GE Healthcare, Milwaukee, WI). Images were reconstructed using filtered back projection and ASIR-V 0%, and a combination of filtered back projection and ASIR-V 20%-80% and ASIR-V 100%. Image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated for left main coronary artery (LM), left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA) and were compared between the different postprocessing algorithms used. Similarly a four-point Likert image quality score of coronary segments was graded for each dataset and compared. A cutoff value of P < .05 was considered statistically significant.
Compared to ASIR-V 0%, ASIR-V 100% demonstrated a significant reduction of image noise in all coronaries (P < .01). Compared to ASIR-V 0%, SNR was significantly higher with ASIR-V 60% in LM (P < .01), LAD (P < .05), LCX (P < .05), and RCA (P < .01). Compared to ASIR-V 0%, CNR for ASIR-V ≥60% was significantly improved in LM (P < .01), LAD (P < .05), and RCA (P < .01), whereas LCX demonstrated a significant improvement with ASIR-V ≥80%. ASIR-V 60% had significantly better Likert image quality scores compared to ASIR-V 0% in segment-, vessel-, and patient-based analyses (P < .01).
Reconstruction with ASIR-V 60% provides the optimal balance between image noise, SNR, CNR, and image quality.
PURPOSE:Recently, a new intracycle motion correction algorithm (MCA) was introduced to reduce motion artifacts from heart rate (HR) in coronary computed tomography angiography (cCTA). The aim of the ...study was to evaluate the image quality, overall evaluability, and effective radiation dose (ED) of cCTA with prospective electrocardiographic (ECG) triggering plus MCA as compared with standard protocol with retrospective ECG triggering in patients with HR≥65 bpm.
MATERIALS AND METHODS:One hundred consecutive patients (67±10 y) scheduled for cCTA with 65<HR<80 bpm were retrospectively analyzed. The patients were assigned to 2 groups undergoing prospective (group 1) or retrospective (group 2) triggered cCTA. The study protocol was approved by the Institutional Ethics Committee and a written informed consent was obtained from all patients. Image noise, signal to noise ratio, contrast to noise ratio, Likert image quality score (score 1, nondiagnostic; score 2, adequate; score 3, good; score 4, excellent), overall image evaluability, and ED were measured and compared between the 2 groups. Both vessel-based and patient-based analyses were evaluated. Student test or Wilcoxon test were used to evaluate differences of continuous variables, whereas the χ test was used to study differences with regard to categorical data. A P-value <0.05 was considered statistically significant.
RESULTS:cCTA was successfully performed in all patients. In a segment-based model, group 1 compared with group 2 showed a lower rate of overall artifacts (67% vs. 83%; P<0.001) and motion artifacts (49% vs. 66%; P<0.001), resulting in a better Likert image quality score (2.83±1.03 vs. 2.37±1.02; P<0.01) and overall evaluability (85% vs. 75%; P<0.01). Group 1 showed a lower ED as compared with group 2 (3.1±1.9 vs. 11.9±3.3 mSv; P<0.01).
CONCLUSION:MCA and cCTA with prospective ECG-triggering acquisition in patients with high HR improves image quality and overall evaluability compared with cCTA with standard retrospective ECG triggering.
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 resynchronization therapy (CRT) has been shown as a successful strategy in the treatment of patients with heart failure and electrical dyssincrony. However, a significant proportion of ...implanted patients fails to respond sufficiently or in a predictable manner. Consequently, non response to CRT remains a valuable problem in clinical practice. In order to improve CRT response and long-term clinical benefits, the proper evaluation of patient's global frialty, the technology improvement, the multimodality imaging approach and the use of simple and low cost electrographic parameters (to verify effective biventricular capture and QRS narrowing) could play a important role. Therefore, the integration of various medical expertises (clinical cardiology, cardiac advanced imaging, electrophysiology) is a crucial element in order to achive the maximal benefits from this promising tecnique. In the multistep process (from patients evaluation to results verification) the follow-up even from the earliest post implantation phase, should be managed with great attention having the potential for impact the prognosis. This brief review focus the problem of non responder to CRT, giving particular attention to the different variables that may play a role (comorbilities, improvement in the tecnology of device implantation, role of multimodality imaging and electrocardiographic parameters).
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