Objectives This study sought to determine the diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTCA) to detect or rule out significant coronary artery disease (CAD). ...Background CTCA is emerging as a noninvasive technique to detect coronary atherosclerosis. Methods We conducted a prospective, multicenter, multivendor study involving 360 symptomatic patients with acute and stable anginal syndromes who were between 50 and 70 years of age and were referred for diagnostic conventional coronary angiography (CCA) from September 2004 through June 2006. All patients underwent a nonenhanced calcium scan and a CTCA, which was compared with CCA. No patients or segments were excluded because of impaired image quality attributable to either coronary motion or calcifications. Patient-, vessel-, and segment-based sensitivities and specificities were calculated to detect or rule out significant CAD, defined as ≥50% lumen diameter reduction. Results The prevalence among patients of having at least 1 significant stenosis was 68%. In a patient-based analysis, the sensitivity for detecting patients with significant CAD was 99% (95% confidence interval CI: 98% to 100%), specificity was 64% (95% CI: 55% to 73%), positive predictive value was 86% (95% CI: 82% to 90%), and negative predictive value was 97% (95% CI: 94% to 100%). In a segment-based analysis, the sensitivity was 88% (95% CI: 85% to 91%), specificity was 90% (95% CI: 89% to 92%), positive predictive value was 47% (95% CI: 44% to 51%), and negative predictive value was 99% (95% CI: 98% to 99%). Conclusions Among patients in whom a decision had already been made to obtain CCA, 64-slice CTCA was reliable for ruling out significant CAD in patients with stable and unstable anginal syndromes. A positive 64-slice CTCA scan often overestimates the severity of atherosclerotic obstructions and requires further testing to guide patient management.
Abstract Background Familial hypercholesterolemia is typically caused by LDL receptor (LDLR) mutations that result in elevated levels of LDL cholesterol (LDL-C). In homozygous FH, the prevalence of ...aortic valve calcification (AoVC) reaches 100% and is often symptomatic. Objectives The objective of this study was to investigate the prevalence, extent, and risk-modifiers of AoVC in heterozygous FH (he-FH) that are presently unknown. Methods Asymptomatic patients with he-FH and 131 non-familial hypercholesterolemia controls underwent CT computed tomography calcium scoring. AoVC was defined as the presence of calcium at the aortic valve leaflets. The extent of AoVC was expressed in Agatston units, as the AoVC-score. We compared the prevalence and extent of AoVC between cases and controls. In addition, we investigated risk modifiers of AoVC, including the presence of LDLR mutations without residual function (LDLR-negative mutations), maximum untreated LDL-cholesterol (maxLDL), LDL-C, blood pressure, and coronary artery calcification (CAC). Results We included 145 asymptomatic patients with he-FH (93 men; mean age 52 ± 8 years) and 131 non-familial hypercholesterolemia controls. The prevalence (%) and AoVC-score (median, IQR) were higher in he-FH patients than in controls: 41%, 51 (9–117); and 21%, 21 (3–49) (p < 0.001 and p = 0.007). Age, untreated maxLDL, CAC, and diastolic blood pressure were independently associated with AoVC. LDLR-negative mutational he-FH was the strongest predictor of the AoVC-score (OR: 4.81; 95% CI: 2.22 to 10.40; p = <0.001). Conclusions Compared to controls, he-FH is associated with a high prevalence and a large extent of subclinical AoVC, especially in patients with LDLR-negative mutations, highlighting the critical role of LDL-C metabolism in AoVC etiology.
We investigated early and late effects of percutaneous revascularization for chronic total coronary occlusion on left ventricular (LV) function and volumes. Magnetic resonance imaging was performed ...in 21 patients before and 5 months and 3 years after recanalization. Global LV function and volumes and segmental wall thickening (SWT) were quantified on cine images. The 2 viability indexes used were the transmural extent of infarction (TEI) on delayed contrast enhancement images and end-diastolic wall thickness at baseline. Significant decreases in mean end-diastolic (86 ± 14 to 78 ± 15 ml/m2 ; p = 0.02) and mean end-systolic volume indexes (35 ± 13 to 30 ± 13 ml/m2 ; p = 0.03) were observed 3 years after recanalization. Mean ejection fraction tended to improve (60 ± 9% to 63 ± 11%; p = 0.11). SWT significantly increased at 5-months’ follow-up (p <0.001), and an additional improvement was found at 3 years’ (p = 0.04) follow-up in segments with TEI <25%. In segments with TEI of 25% to 75%, SWT was unchanged at 5-month follow-up (p = 0.89), but improved at 3 years (p = 0.04). SWT was unchanged in segments with transmural scars. For segmental functional recovery, TEI was a better predictor than end-diastolic wall thickness at baseline (odds ratio 5.6, 95% confidence interval 1.5 to 21.1, p = 0.01 vs odds ratio 2.5, 95% confidence interval 0.7 to 8.3, p = 0.14). In conclusion, a positive effect on LV remodeling and ejection fraction was observed up to 3 years after recanalization. Both early and late improvements in regional LV function were observed in the perfusion territory of chronic total coronary occlusion and were related to the transmural extent of infarction on pretreatment magnetic resonance imaging.
64-Slice Computed Tomography Coronary Angiography in Patients With High, Intermediate, or Low Pretest Probability of Significant Coronary Artery Disease W. Bob Meijboom, Carlos A. G. van Mieghem, ...Nico R. Mollet, Francesca Pugliese, Annick C. Weustink, Niels van Pelt, Filippo Cademartiri, Koen Nieman, Eric Boersma, Peter de Jaegere, Gabriel P. Krestin, Pim J. de Feyter We assessed the usefulness of 64-slice computed tomography (CT) coronary angiography to detect or rule out coronary artery disease (CAD) in patients with various estimated pretest probabilities. The estimated pretest probability of CAD in patients with high, intermediate, or low pretest probability was 87%, 53%, and 13%. The estimated post-test probability of a negative CT scan was 17%, 0%, and 0%, and of a positive CT scan was 96%, 88%, and 68%. Computed tomography coronary angiography is useful in symptomatic patients with low or intermediate estimated pretest probability of having CAD and does not provide additional diagnostic information in patients with a high estimated pretest probability.
Objectives This study sought to analyze the natural history of coronary atherosclerosis by multislice computed tomography (MSCT) and assess the serial changes in coronary plaque burden, lumen ...dimensions, and arterial remodeling. Background MSCT can comprehensively assess coronary atherosclerosis by combining lumen and plaque size parameters. Methods Thirty-two patients with acute coronary syndromes underwent 64-slice computed tomography angiography after percutaneous coronary intervention at baseline and after a median of 39 months. All patients received contemporary medical treatment. All available coronary segments in every subject were analyzed. The progression of atherosclerosis per segment and per patient was assessed by means of change in percent atheroma volume (PAV), change in normalized total atheroma volume (TAVnorm), and percent change in TAV (% change in TAV). Serial coronary remodeling was also assessed. Measures of lumen stenosis included percent diameter stenosis (%DS), minimum lumen diameter (MLD), percent area stenosis (%AS), and minimum lumen area (MLA). For each patient, the mean of all matched segments was calculated at the 2 time points. Clinical events at follow-up were documented. Results The PAV did not change significantly (−0.15 ± 3.64%, p = 0.72). The mean change in TAVnorm was 47.36 ± 143.24 mm3 (p = 0.071), and the % change in TAV was 6.7% (p = 0.029). The MLD and MLA increased by 0.15 mm (−0.09 to 0.24, p = 0.039) and 0.52 mm2 (−0.38 to 1.04, p = 0.034) respectively, which was accompanied by vessel enlargement, with 53% of the patients showing expansive positive remodeling. Patients with clinical events had a larger TAVnorm at baseline (969.72 mm3 vs. 810.77 mm3 , p = 0.010). Conclusions MSCT can assess the progression of coronary atherosclerosis and may be used for noninvasive monitoring of pharmacological interventions in coronary artery disease. (PROSPECT: An Imaging Study in Patients With Unstable Atherosclerotic Lesions; NCT00180466 )
Usefulness of 64-Slice Multislice Computed Tomography Coronary Angiography to Assess In-Stent Restenosis Filippo Cademartiri, Joanne D. Schuijf, Francesca Pugliese, Nico R. Mollet, J. Wouter Jukema, ...Erica Maffei, Lucia J. Kroft, Alessandro Palumbo, Diego Ardissino, Patrick W. Serruys, Gabriel P. Krestin, Ernst E. Van der Wall, Pim J. de Feyter, Jeroen J. Bax The purpose of the present study was to evaluate the diagnostic accuracy of 64-slice multislice computed tomography (MSCT) coronary angiography in the follow-up of patients with previous coronary stent implantation. In 182 patients with 192 previously implanted stents, 64-slice MSCT angiography was performed in addition to quantitative coronary angiography to evaluate the presence of in-stent restenosis (≥50%). In total, 14 (7.3%) stents were uninterpretable. In the interpretable stents, sensitivity, specificity, and positive and negative predictive value to identify in-stent restenosis were 95.0%, 93.0%, 63.3%, and 99.3%, respectively. Accordingly, 64-slice MSCT may be valuable as a noninvasive method of excluding in-stent restenosis.
Objectives Using multislice computed tomography (MSCT), we sought to evaluate the geometry and apposition of the CoreValve ReValving System (CRS, Medtronic, Luxembourgh, Luxembourgh) in patients with ...aortic stenosis. Background There are no data on the durability of percutaneous aortic valve replacement. Geometric factors may affect durability. Methods Thirty patients had MSCT at a median 1.5 months (interquartile range IQR 0 to 7 months) after percutaneous aortic valve replacement. Axial dimensions and apposition of the CRS were evaluated at 4 levels: 1) the ventricular end; 2) the nadir; 3) central coaptation of the CRS leaflets; and 4) commissures. Orthogonal smallest and largest diameters and cross-sectional surface area were measured at each level. Results The CRS (26-mm: n = 14, 29-mm: n = 16) was implanted at 8.5 mm (IQR 5.2 to 11.0 mm) below the noncoronary sinus. None of the CRS frames reached nominal dimensions. The difference between measured and nominal cross-sectional surface area at the ventricular end was 1.6 cm2 (IQR 0.9 to 2.6 cm2 ) and 0.5 cm2 (IQR 0.2 to 0.7 cm2 ) at central coaptation. At the level of central coaptation the CRS was undersized relative to the native annulus by 24% (IQR 15% to 29%). The difference between the orthogonal smallest and largest diameters (degree of deformation) at the ventricular end was 4.4 mm (IQR 3.3 to 6.4 mm) and it decreased progressively toward the outflow. Incomplete apposition of the CRS frame was present in 62% of patients at the ventricular end and was ubiquitous at the central coaptation and higher. Conclusions Dual-source MSCT demonstrated incomplete and nonuniform expansion of the CRS frame, but the functionally important mid-segment was well expanded and almost symmetrical. Undersizing and incomplete apposition were seen in the majority of patients.
Reliable High-Speed Coronary Computed Tomography in Symptomatic Patients Annick C. Weustink, Willem B. Meijboom, Nico R. Mollet, Masato Otsuka, Fransesca Pugliese, Carlos van Mieghem, Roberto Malago, ...Niels van Pelt, Marcel L. Dijkshoorn, Filippo Cademartiri, Gabriel P. Krestin, Pim J. de Feyter We assessed the diagnostic performance of the high-speed dual source computed tomography scanner (DSCT) for the detection of significant coronary lesions in a clinically wide range of patients. Sensitivity, specificity, and positive and negative predictive values of DSCT coronary angiography for the detection of significant lesions on a segment-by-segment analysis were 95%, 95%, 75%, and 99%, respectively, and on a patient-based analysis 99%, 87%, 96%, and 95%, respectively. Noninvasive DSCT coronary angiography is highly sensitive to detect and to reliably rule out the presence of a significant coronary stenosis in patients presenting with atypical or typical angina pectoris, or unstable coronary artery disease.
We compared the diagnostic accuracy of 64-slice computed tomographic (CT) coronary angiography to detect significant coronary artery disease (CAD) in women and men. The 64-slice CT coronary ...angiography was performed in 402 symptomatic patients, 123 women and 279 men, with CAD prevalence of 51% and 68%, respectively. Significant CAD, defined as ≥50% coronary stenosis on quantitative coronary angiography, was evaluated on a patient, vessel, and segment level. The sensitivity and negative predictive value to detect significant CAD was very good, both for women and men (100% vs 99%, p = NS; 100% vs 98%, p = NS), whereas diagnostic accuracy (88% vs 96%; p <0.01), specificity (75% vs 90%, p <0.05), and positive predictive value (81% vs 95%, p <0.001) were lower in women. The per-segment analysis demonstrated lower sensitivity in women compared with men (82% vs 93%, p <0.001). The sensitivity in women did not show a difference in proximal and midsegments, but was significantly lower in distal segments (56% vs 85%, p <0.05) and side branches (54% vs 89%, p <0.001). In conclusion, CT coronary angiography reliably rules out the presence of obstructive CAD in both men and women. Specificity and positive predictive value of CT coronary angiography were lower in women. The sensitivity to detect stenosis in small coronary branches was lower in women compared with men.
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