Two-dimensional speckle-tracking applied to dobutamine stress echocardiography (DSE) may aid in the detection of coronary artery disease (CAD). The aim of this study was to determine the value of ...strain, strain rate, and postsystolic strain index (PSI) measured by speckle-tracking during DSE in the evaluation of the presence, extent, and severity of myocardial ischemia.
Fifty patients 63 ± 7 years of age with intermediate probability of CAD were prospectively recruited. All patients underwent DSE, quantitative positron emission tomographic perfusion imaging, and invasive angiography. Regional peak systolic longitudinal strain, strain rate, and PSI were measured at rest, at a dobutamine dose of 20 μg/kg/min, at peak stress, and at early recovery (1 min after stress). Obstructive CAD was defined as >75% stenosis or 40% to 75% stenosis combined with either fractional flow reserve < 0.80 or abnormal findings on myocardial perfusion positron emission tomography.
Obstructive CAD was detected in 22 patients and in 36 of 150 coronary arteries. Strain analyses showed the highest reproducibility at rest, at a dobutamine dose of 20 μg/kg/min, and at early recovery. Increased PSI and reduced strain during early recovery were the strongest predictors of obstructive CAD and were associated with the extent, localization, and depth of myocardial ischemia by positron emission tomography. On vessel-based analysis, strain, PSI, and visual analysis of wall motion provided comparable diagnostic accuracy, whereas the combination of strain or PSI with visual analysis provided incremental value over visual analysis alone.
Assessment of systolic or postsystolic strain by speckle-tracking echocardiography during early recovery after DSE can help in the detection of hemodynamically significant coronary stenosis compared with visual wall motion analysis alone.
In interventional cardiology (IC) the radiation dose variation is very significant, and its estimation has been difficult due to the complexity of the treatments. In order to tackle this problem, the ...aim of this study was to identify the most important demographic and clinical features to estimate Kerma-Area Product (KAP) radiation dose in coronary angiographies (CA) and percutaneous coronary interventions (PCI). The study was retrospective using clinical patient data from 838 CA and PCI procedures. A total of 59 features were extracted from the patient data and 9 different filter-based feature selection methods were used to select the most informative features in terms of the KAP radiation dose from the treatments. The selected features were then used in a support vector regression (SVR) model to evaluate their performance in estimating the radiation dose. The ten highest-ranking features were: (1) FN1AC (CA), (2) FN2BA (PCI), (3) weight, (4) post-stenosis 0%, (5) multi-vessel disease, (6) number of procedures 3, (7) pre-stenosis 100%, (8) American Heart Association (AHA) score C, (9) pre-stenosis 85% and (10) gender. The performance of the SVR model increased (mean squared error ≈ 450) with the number of features approximately up to 30 features. The identification of the most informative features for CA and PCI KAP is an important step in determining suitable complexity models for clinical practice. The highest-ranking features can be used as individual predictors of IC procedure KAP or can be incorporated into combined complexity score or different estimation models in the future.
•In interventional cardiology (IC) the radiation dose variation is very significant and its estimation has been difficult due to the complexity of the treatments.•This study utilises multiple filter-based feature selection methods to identify the most informative patient demographic and clinical features for estimating the KAP radiation dose in coronary angiographies (CA) and percutaneous coronary interventions (PCI).•The features chosen by the feature selection methods were then used in a supervised machine learning model to evaluate their performance in estimating the induced radiation dose.•Beyond the benefits to scientific work on procedure complexity, the results of this study can be utilised to establish more accurate difficulty level-based DRLs and personalised dosimetry measures for patients at risk of high dose.
The study evaluated the quality of cardiovascular prevention in real-world clinical practice. The recurrence of up to five cardiovascular events was assessed, as data on recurrence beyond the first ...event and interindividual variations in event rates past the second event have been sparse. Low-density lipoprotein cholesterol concentrations and lipid-lowering therapy use were investigated.
This retrospective register-based study included adult patients with an incident cardiovascular event between 2004 and 2016 treated in the hospital district of southwest Finland. Patients were followed for consecutive cardiovascular events or cardiovascular death, low-density lipoprotein cholesterol and statin purchases. The timing of event recurrence was evaluated, and predictive factors were assessed.
A wide interindividual variation in cardiovascular event recurrence was observed, each additional event caused an increased risk, the median time of recurrence decreased from 7 to one year for the second and fifth event. Event rates increased correspondingly from 12 to 43/100 patient-years and were most pronounced in the first years following the previous event. The low-density lipoprotein cholesterol goal (<1.8 mmol/l) was reached by 18% in the year after the event and statin underuse was associated with an increased risk of recurrence. Six months after the index event high intensity statins were used by only 22% of the cohort.
The study provides new perspectives on individual risk assessment showing that event rates are not stable for all patients but increase 1.2-1.9-fold per consecutive event. The underuse of statins and poor adherence support the identification of these patients for intensified multifactorial preventive measures.
It is unknown whether the preferred 1-stent bifurcation stenting approach with stenting of the main vessel (MV) and optional side branch stenting using drug-eluting stents should be finalized by a ...kissing balloon dilatation (FKBD). Therefore, we compared strategies of MV stenting with and without FKBD.
We randomized 477 patients with a bifurcation lesion to FKBD (n=238) or no FKBD (n=239) after MV stenting. The primary end point was major adverse cardiac events: cardiac death, non-procedure-related index lesion myocardial infarction, target lesion revascularization, or stent thrombosis within 6 months. The 6-month major adverse cardiac event rates were 2.1% and 2.5% (P=1.00) in the FKBD and no-FKBD groups, respectively. Procedure and fluoroscopy times were longer and more contrast media was needed in the FKBD group than in the no-FKBD group. Three hundred twenty-six patients had a quantitative coronary assessment. At 8 months, the rate of binary (re)stenosis in the entire bifurcation lesion (MV and side branch) was 11.0% versus 17.3% (P=0.11), in the MV was 3.1% versus 2.5% (P=0.68), and in the side branch was 7.9% versus 15.4% (P=0.039) in the FKBD versus no-FKBD groups, respectively. In patients with true bifurcation lesions, the side branch restenosis rate was 7.6% versus 20.0% (P=0.024) in the FKBD and no-FKBD groups, respectively.
MV stenting strategies with and without FKBD were associated with similar clinical outcomes. FKBD reduced angiographic side branch (re)stenosis, especially in patients with true bifurcation lesions. The simple no-FKBD procedures resulted in reduced use of contrast media and shorter procedure and fluoroscopy times. Long-term data on stent thrombosis are needed. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00914199.
Objectives
To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting.
Methods
Patients with suspected CAD and ...stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA.
Results
In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both
p
< 0.001), but overestimation of disease prevalence was higher for the initial D+F (
p
< 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval CI 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F;
p
< 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16,
p
< 0.001).
Conclusions
Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed.
Trial registration
https://www.clinicaltrials.gov/ct2/show/NCT02400229
Key Points
• Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT.
• Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F.
• Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.
Abstract Objectives This study observed hemodynamic consequences of myocardial bridging and its relation to coronary atherosclerosis. Background Myocardial bridging is seen as intramural course by ...computed tomography angiography (CTA) or systolic compression by invasive coronary angiography. Segments with myocardial bridging are in previous studies closely associated with proximal atherosclerotic plaques. Methods We prospectively studied 100 patients 63 ± 7 years of age with intermediate likelihood of coronary artery disease. Segments with superficial (>1 mm) or deep (>2 mm) intramural course were identified using CTA. Myocardial perfusion was studied by 15-Oxygen water positron emission tomography and systolic compression by invasive coronary angiography. Results Myocardial bridging was detected in 34 (34%) patients in 48 different vascular segments. Of these, 24 (50%) were deep and systolic compression was present in 14 (29%). In patients without obstructive coronary artery disease, myocardial stress perfusion distal to myocardial bridging was comparable with remote control regions (3.3 ± 0.9 ml/g/min vs. 3.3 ± 0.7 ml/g/min, n = 24, p = 0.88). Stress perfusion was comparable in segments with and without systolic compression (3.0 ± 0.9 vs. 2.7 ± 1.0 ml/g/min, p = 0.43). Atherosclerotic plaques were more frequent in proximal (71%) than myocardial bridging (7%) or distal (21%) segments. The presence of atherosclerosis and the average number of plaques were comparable in coronary arteries with and without myocardial bridging (73% vs. 60%, p = 0.14 and 2.0 ± 1.7 vs. 1.5 ± 1.6, p = 0.06). Median Agatston coronary calcium score was not elevated in vessels with myocardial bridge (15 interquartile range: 0, 129 vs. 50 interquartile range: 0, 241, p = 0.21). Conclusions Myocardial bridging of coronary arteries is common on CTA, but only approximately one-third of these show systolic compression. Myocardial bridging is not associated with reduced myocardial perfusion during vasodilator stress. Atherosclerosis is located predominantly proximal to myocardial bridging but atherosclerotic burden and presence of vulnerable plaques were comparable.
To study the association between risk factors and chronic kidney disease (CKD), and characterize medication use in Finnish primary care type 2 diabetes (T2D) patients.
Data on clinical ...characteristics, laboratory measurements, and medications were collected from medical records. The primary outcome measure was notable CKD (stage 3-5, eGFR <60 ml/min/1.73 m
) and/or increased albuminuria. The explanatory variables were individual risk factors and risk factor groups based on their number (0-2, 3-4, 5-6, >7). Spearman's rank correlation coefficient and risk ratio analysis were used to analyze the association between the number of risk factors and CKD stage, and between the number of risk factors and notable CKD, respectively.
Altogether, 1335 patients with T2D in 60 Finnish primary care centers were recruited for this cross-sectional study. Three-quarters of T2D patients had 3 risk factors and 36% had ≥ 5 risk factors. Compared to patients with 0-2 risk factors, patients with 3-4, 5-6, and ≥ 7 risk factors had a 5.5-fold, 9.9-fold, and 15.9-fold risk of notable CKD (p < 0.001), respectively. Heart failure was most strongly associated with notable CKD (risk ratio, 3.7; p < 0.001).
Number of risk factors was strongly associated with advanced-stage CKD.
Abstract
Aims
Coronary microvascular dysfunction (CMD) can cause angina in the absence of obstructive coronary artery disease (CAD). We studied the frequency and angiographic characteristics of CMD ...in symptomatic patients with suspected stable CAD and identified CMD as diffusely abnormal coronary vasodilator capacity by positron emission tomography (PET) perfusion imaging.
Methods and results
We recruited prospectively 189 patients with intermediate pre-test probability of CAD who underwent coronary computed tomography angiography and quantitative 15O-water PET perfusion imaging followed by invasive coronary angiography, and assessment of fractional flow reserve when feasible. Prevalence of obstructive epicardial CAD was 37%. Absolute myocardial blood flow was diffusely reduced (<2.4 mL/g/min) within the left ventricle during adenosine stress in 32 (17%) patients. In 15 (8%) patients, this was explained by three-vessel obstructive CAD, whereas the remaining 17 (9%) were diagnosed with CMD. Of these, 2 (1% of all patients) had no coronary atherosclerosis, 5 (3% of all patients) had non-obstructive atherosclerosis, and in 10 (5% of all patients) CMD co-existed with obstructive CAD. Atypical angina or non-anginal chest pain (53%) was the most common presentation. Older age and male sex were associated with CMD, but other risk factors of CAD were equally common in patients with or without CMD.
Conclusion
Coronary microvascular dysfunction exists in 9% of symptomatic stable patients with suspected CAD. However, the prevalence of microvascular dysfunction without any coronary atherosclerosis is low (1%) in this population.
Aims To assess the efficacy and safety of bone marrow cell (BMC) therapy after thrombolytic therapy of an acute ST-elevation myocardial infarction (STEMI). Methods and results Patients with STEMI ...treated with thrombolysis followed by percutaneous coronary intervention (PCI) 2–6 days after STEMI were randomly assigned to receive intracoronary BMCs (n = 40) or placebo medium (n = 40), collected and prepared 3–6 h prior PCI and injected into the infarct artery immediately after stenting. Efficacy was assessed by the measurement of global left ventricular ejection fraction (LVEF) by left ventricular angiography and 2-D echocardiography, and safety by measuring arrhythmia risk variables and restenosis of the stented vessel by intravascular ultrasound. At 6 months, BMC group had a greater absolute increase of global LVEF than placebo group, measured either by angiography (mean ± SD increase 7.1 ± 12.3 vs. 1.2 ± 11.5%, P = 0.05) or by 2-D echocardiography (mean ± SD increase 4.0 ± 11.2 vs. −1.4 ± 10.2%, P = 0.03). No differences were observed between the groups in the adverse clinical events, arrhythmia risk variables, or the minimal lumen diameter of the stented coronary lesion. Conclusion Intracoronary BMC therapy is associated with an improvement of global LVEF and neutral effects on arrhythmia risk profile and restenosis of the stented coronary lesions in patients after thrombolytic therapy of STEMI.
Preclinical studies reveal the neuroprotective properties of xenon, especially when combined with hypothermia. The purpose of this study was to investigate the feasibility and cardiac safety of ...inhaled xenon treatment combined with therapeutic hypothermia in out-of-hospital cardiac arrest patients.
An open controlled and randomized single-centre clinical drug trial (clinicaltrials.gov NCT00879892).
A multipurpose ICU in university hospital.
Thirty-six adult out-of-hospital cardiac arrest patients (18-80 years old) with ventricular fibrillation or pulseless ventricular tachycardia as initial cardiac rhythm.
Patients were randomly assigned to receive either mild therapeutic hypothermia treatment with target temperature of 33°C (mild therapeutic hypothermia group, n=18) alone or in combination with xenon by inhalation, to achieve a target concentration of at least 40% (Xenon+mild therapeutic hypothermia group, n=18) for 24 hours. Thirty-three patients were evaluable (mild therapeutic hypothermia group, n=17; Xenon+mild therapeutic hypothermia group, n=16).
Patients were treated and monitored according to the Utstein protocol. The release of troponin-T was determined at arrival to hospital and at 24, 48, and 72 hours after out-of-hospital cardiac arrest. The median end-tidal xenon concentration was 47% and duration of the xenon inhalation was 25.5 hours. The frequency of serious adverse events, including inhospital mortality, status epilepticus, and acute kidney injury, was similar in both groups and there were no unexpected serious adverse reactions to xenon during hospital stay. In addition, xenon did not induce significant conduction, repolarization, or rhythm abnormalities. Median dose of norepinephrine during hypothermia was lower in xenon-treated patients (mild therapeutic hypothermia group=5.30 mg vs Xenon+mild therapeutic hypothermia group=2.95 mg, p=0.06). Heart rate was significantly lower in Xenon+mild therapeutic hypothermia patients during hypothermia (p=0.04). Postarrival incremental change in troponin-T at 72 hours was significantly less in the Xenon+mild therapeutic hypothermia group (p=0.04).
Xenon treatment in combination with hypothermia is feasible and has favorable cardiac features in survivors of out-of-hospital cardiac arrest.
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