Treatment of breast cancer with trastuzumab is complicated by cardiotoxicity in up to 34% of the patients. In most patients, trastuzumab-induced cardiotoxicity (TIC) is reversible: left ventricular ...ejection fraction (LVEF) improves after trastuzumab withdrawal and with, or sometimes without, initiation of heart failure (HF) therapy. The reversibility of TIC, however, is not foreseeable, and identification of patients at risk and of those who will not recover from cardiac dysfunction is crucial. The usefulness of troponin I (TNI) in the identification of patients at risk for TIC and in the prediction of LVEF recovery has never been investigated.
In total, 251 women were enrolled. TNI was measured before and after each trastuzumab cycle. LVEF was evaluated at baseline, every 3 months during trastuzumab therapy, and every 6 months afterward. In case of TIC, trastuzumab was discontinued, and HF treatment with enalapril and carvedilol was initiated. TIC was defined as LVEF decrease of > 10 units and below 50%. Recovery from TIC was defined as LVEF increase above 50%.
TIC occurred in 42 patients (17%) and was more frequent in patients with TNI elevation (TNI+; 62% v 5%; P < .001). Twenty-five patients (60%) recovered from TIC. LVEF recovery occurred less frequently in TNI+ patients (35% v 100%; P < .001). At multivariate analysis, TNI+ was the only independent predictor of TIC (hazard ratio HR, 22.9; 95% CI, 11.6 to 45.5; P < .001) and of lack of LVEF recovery (HR, 2.88; 95% CI,1.78 to 4.65; P < .001).
TNI+ identifies trastuzumab-treated patients who are at risk for cardiotoxicity and are unlikely to recover from cardiac dysfunction despite HF therapy.
Objectives The aim of this study was to assess the long-term prognostic role of multidetector computed tomography coronary angiography (CTA) in patients with suspected coronary artery disease (CAD). ...Background Use of CTA is increasing in patients with suspected CAD. Although there is a large body of data supporting the prognostic role of CTA for major adverse cardiac events in the intermediate term, its long-term prognostic role in patients with suspected CAD is not well studied. Methods Between February 2005 and March 2008, 1,304 consecutive patients were prospectively studied with CTA for detecting the presence and assessing extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronaries and nonobstructive (<50%) and obstructive (>50%) coronary lesions. The composite rates of hard cardiac events (cardiac deaths and nonfatal myocardial infarctions) and all cardiac events (including late revascularization) were the endpoints of the study. Results Seventy patients were excluded because their CTA data were uninterpretable. Of the remaining 1,234 patients, clinical follow-up (mean 52 ± 22 months) was obtained for 1,196 (97%). A total of 475 events were recorded, with 136 hard events (18 cardiac deaths and 118 nonfatal myocardial infarctions) and 123 late revascularizations. A total of 216 patients with early elective revascularizations were excluded from the survival analysis. Significant independent predictors of events in multivariate analysis were multivessel disease and left main CAD. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 88% for hard events and 72% for all events in patients with nonobstructive CAD, and 54% for hard events and 31% for all events in patients with obstructive CAD. Multivessel CAD was associated with a higher rate of hard cardiac events. Conclusions CTA provides prognostic information in patients with suspected CAD and unknown cardiac disease, showing excellent long-term prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present.
To compare the image quality, evaluability, diagnostic accuracy, and radiation exposure of high-spatial-resolution (HR, 0.23-mm) computed tomographic (CT) coronary angiography with standard spatial ...resolution (SR, 0.625-mm) 64-section imaging in patients at high risk for coronary artery disease (CAD) by using invasive coronary angiography (ICA) as the reference method.
Written informed consent was obtained from all patients, and the study protocol was approved by the institutional ethical committee. Patients at high risk for CAD (n = 184) who were scheduled for ICA were randomly assigned for study with SR (n = 91) or HR (n = 93) coronary CT angiography before they underwent ICA. To compare the two groups, the Student t test or Wilcoxon test were used to evaluate differences in continuous variables. The χ(2) test or Fisher exact test were used, as appropriate, for categorical data. The McNemar test was used to compare the diagnostic performance of coronary CT angiography versus that of ICA in each group.
HR coronary CT angiography showed a higher image quality score (3.7 vs 3.4, P < .001) and evaluability (97% vs 92%, P < .002). In a segment-based analysis, HR coronary CT angiography showed a higher specificity, positive predictive value, and accuracy in comparison with SR coronary CT angiography (98%, 91%, and 99% vs 95%, 80%, and 95%, respectively; P < .001). Moreover, HR coronary CT angiography showed a better agreement with ICA for calcified plaques compared with SR coronary CT angiography and ICA (83% vs 53%, P < .001). In a patient-based analysis, HR coronary CT angiography showed higher specificity and accuracy compared with SR coronary CT angiography (91% and 98% vs 46% and 92%, respectively; P < .01). No differences in radiation exposure were found between the two groups.
Improved evaluability and accuracy were seen with HR compared with SR coronary CT angiography of calcified coronary artery lesions, suggesting a potential use for this technology in patients at high risk for CAD.
Statin pretreatment has been reported to have a cardioprotective effect in patients undergoing elective or urgent percutaneous coronary intervention (PCI). However, data on patients with ST-elevation ...myocardial infarction (STEMI) undergoing primary PCI are still controversial. We prospectively evaluated the effect of long-term statin therapy on infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) in consecutive patients with STEMI who underwent primary PCI. Two-hundred thirty patients with STEMI (mean age 61 ± 11 years, 183 men) who underwent primary PCI were evaluated with cardiac magnetic resonance (CMR) imaging during hospitalization (median 4 days after primary PCI). In all patients, we measured peak troponin I level, whereas IS, MSI, and MVO were determined by CMR. Fifty patients (22%) were on long-term statin therapy and showed a significantly lower troponin I peak value compared to patients without previous statins (54 ± 47 vs 88 ± 106 ng/ml; p = 0.02). At CMR evaluation, IS related to the index event was significantly smaller (12.5 ± 11.5 vs 18.5 ± 18.5 g, p = 0.05), and MSI was higher (0.68 ± 0.25 vs 0.52 ± 0.30; p <0.01) in patients with previous statin therapy. MVO was also less frequent (10% vs 20%; p = 0.14) in this group. At multivariate analysis, previous statin therapy remained significantly associated with IS and MSI (p = 0.05 and 0.02, respectively). In conclusion, this study suggests that long-term statin therapy before primary PCI in patients with STEMI is associated with smaller IS and higher MSI. Future studies are warranted to confirm these findings and to investigate potential clinical implications.
Background The aim of this study was to assess the accuracy of a comprehensive multidetector computed tomography (MDCT) evaluation of the aortic annulus (AoA), coronary artery disease (CAD), and ...peripheral vessels in patients referred for transcatheter aortic valve implantation (TAVI). Methods In 60 patients referred for TAVI, the following parameters were assessed with 64-slices MDCT and compared with transesophageal echocardiography (TEE), invasive coronary angiography (ICA), and peripheral angiography: AoA maximum diameter (Max-AoA-DMDCT ), minimum diameter (Min-AoA-DMDCT ), and area; lumen morphology index (Max-AoA-DMDCT /Min-AoA-DMDCT ); length of the left, right, and non-coronary aortic leaflets; degree (grades 1-4) of aortic leaflet calcifications; distance between AoA and left main coronary ostium and between AoA and right coronary ostium CAD and peripheral vessel disease. Results The Max-AoA-DMDCT and Min-AoA-DMDCT were 25.1 ± 2.8 and 21.2 ± 2.2 mm, respectively, with high correlation versus AoA diameter measured with TEE (r = 0.82 and 0.86, respectively). The area of AoA, systolic and diastolic lumen morphology index were 410 ± 81.5 mm2 , 1.19 ± 0.1 and 1.22 ± 0.11, respectively. Aortic leaflet calcification score was 3.3 ± 0.5. The lengths of left, right, and non-coronary aortic leaflets were 14.2 ± 2.4, 13.7.1 ± 2.1, and 14.5 ± 2.6 mm, whereas distances between AoA and the left main coronary ostium and between AoA, and the right coronary ostium were 13.7 ± 2.9 and 15.8 ± 3.5 mm, respectively. Feasibility, negative predictive value, and accuracy for CAD detection versus ICA were 87%, 100% (CI 100-100), and 96% (95% CI 94-100), respectively. All patients (N = 17) who were ineligible for TAVI were correctly detected by MDCT. Conclusions A comprehensive MDCT evaluation of patients referred for TAVI is feasible, provides more accurate assessment than TEE of AoA morphology, and may replace peripheral angiography in all patients and ICA in patients without significant CAD.
The evaluation of the aortic root in patients referred for transcatheter aortic valve implantation is crucial. The aim of the present study was to compare the accuracy of cardiac magnetic resonance ...(CMR) evaluation of the aortic annulus (AoA) with transthoracic and transesophageal echocardiography and multidetector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation. In 50 patients, maximum diameter, minimum diameter and AoA, length of the left coronary, right coronary, and noncoronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification, and distance between AoA and coronary artery ostia were assessed. AoA maximum diameter, minimum diameter, and area by CMR were 26.4 ± 2.8 mm, 20.6 ± 2.3 mm, 449.8 ± 86.2 mm2 , respectively. The length of left coronary, right coronary, and noncoronary leaflets by CMR were 13.9 ± 2.2, 13.3 ± 2.1, and 13.4 ± 1.8 mm, respectively, whereas the score of aortic leaflet calcifications was 2.9 ± 0.8. Finally, the distances between AoA and left main and right coronary artery ostia were 16.1 ± 2.8 and 16.1 ± 4.4 mm, respectively. Regarding AoA area, transthoracic and transesophageal echocardiography showed an underestimation (p <0.01), with a moderate agreement (r: 0.5 and 0.6, respectively, p <0.01) compared with CMR. No differences and excellent correlation were observed between CMR and MDCT for all parameters (r: 0.9, p <0.01), except for aortic leaflet calcifications that were underestimated by CMR. In conclusion, aortic root assessment with CMR including AoA size, aortic leaflet length, and coronary artery ostia height is accurate compared with MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.
Objectives The aim of the study was to perform a comparison of the prognostic performance of computed tomography coronary angiography (CTA) and exercise electrocardiography (ex-ECG) in patients with ...suspected coronary artery disease (CAD). Background CAD is a major cause of mortality and morbidity, and its management consumes a large proportion of the health care budget. Therefore, identification of patients at high risk of adverse events is crucial. Despite its limited accuracy, ex-ECG is the most commonly used noninvasive test in CAD evaluation. CTA was recently introduced as alternative test. Methods We enrolled 681 patients (age 61.3 ± 10.4 years, 461 men) with atypical or typical angina and no history of CAD. All patients underwent ex-ECG and CTA and were followed for 44 ±12 months. The endpoints were all cardiac events, defined as nonfatal myocardial infarction, cardiac death, and revascularization, and hard cardiac events, defined as all cardiac events excluding revascularization. Results ex-ECG and CTA were rated as positive in 419 (61%) and 274 (40%) of 681 patients, respectively. In univariate analysis, both ex-ECG and CTA were predictors of all cardiac events (hazard ratio HR: 2.09, 95% confidence interval CI: 1.5 to 2.8; p < 0.0001 and HR: 21.1, 95% CI: 14.6 to 30.5; p < 0.0001, respectively) and hard cardiac events (HR: 1.9, 95% CI: 1.1 to 3.2; p = 0.02 and HR: 6.8, 95% CI: 3.9 to 11.0; p < 0.0001, respectively), whereas in a multivariate analysis, CAD with ≥50% stenoses detected by CTA was the only independent predictor of hard cardiac events. Stratifying our population by ex-ECG and CTA findings, Kaplan-Meier curves showed that ex-ECG provides only a further risk stratification in the subset of patients with positive findings on CTA and a low to intermediate likelihood of CAD. Moreover, positive findings on CTA identify a shorter event-free period, regardless the ex-ECG findings for both all cardiac events and hard cardiac events, respectively. Conclusions CTA may have a higher prognostic value compared with ex-ECG in patients with suspected CAD, mainly in those with a low to intermediate pre-test likelihood of CAD.
Noninvasive assessment of coronary in-stent restenosis (ISR) is clinically useful but 4- and 16-slice multidetector computed tomography is limited due to stent strut artifacts. We evaluated the ...feasibility and accuracy of 64-slice multidetector computed tomography in the diagnosis of ISR to validate its accuracy in ISR quantification and identify factors that may affect stent patency evaluability. One hundred patients with previously implanted coronary stents (n = 179) underwent 64-slice multidetector computed tomography followed by invasive coronary angiography. After multidetector computed tomography, each stent was classified as “evaluable” or “unevaluable.” Obstructive ISR was visually and quantitatively determined in evaluable stents. Correlations between quantitative multidetector computed tomography and quantitative coronary angiography were estimated. In a subgroup, multidetector computed tomographic and intravascular ultrasound measurements were correlated. Feasibility of stent visualization was 95%. Thirty-four of 39 ISRs (87%) were correctly detected and localized by multidetector computed tomography. ISR was correctly ruled out for 77% (128 of 131) of remaining stented lesions. Sensitivity, specificity, and positive and negative predictive values of multidetector computed tomography for ISR identification were 87%, 98%, 92%, and 96%, respectively. There was good correlation between percent stenosis evaluated by multidetector computed tomography versus quantitative coronary angiography and intravascular ultrasound (r = 0.794, p <0.001, and r = 0.943, p <0.0001, respectively) and good reproducibility of multidetector computed tomographic measurements (interobserver coefficient k 0.81 for diameter and 0.79 for area). Heart rate, complexity of stenting procedure, stent diameter, and strut thickness were factors limiting feasibility and accuracy. In conclusion, 64-slice multidetector computed tomography provides reliable and reproducible noninvasive evaluation of coronary stent patency and quantification of ISR.
Abstract It is unknown whether multidetector computed tomography (MDCT) has an additional clinical value compared to invasive coronary angiography (ICA) in the characterization of congenital coronary ...artery anomalies (CAA). We studied 2757 consecutive patients with 64-slice MDCT and classified CAA according to anatomical criteria and pathophysiology–clinical relevance. The prevalence of anatomical variants was: left dominance circulation (8%), absence of left main artery (1.3%), presence of intermediate ramus (22.6%), origin of conus branch from aorta (10.6%) and of the sinus node branch from the left circumflex coronary artery (15.3%). Among 380 CAA (13.8 %) detected with MDCT, 322 (85%) were an occasional finding. In the remaining 58 patients, MDCT performed after ICA confirmed CAA in 40 (69%) cases and detected or provided additional and more detailed informations in 18 (31%). Of these 18 patients, 14 showed malignant CAA. MDCT is the ideal method for the evaluation of CAA, not only allowing a precise anatomic visualization of coronary tree, but also adding important details in malignant congenital anomalies.
Diabetics have high prevalence of subclinical coronary artery disease (CAD) with typical characteristics (diffuse disease, large calcifications). Although 64-slice multidetector computed tomography ...(MDCT) coronary angiography has high diagnostic accuracy to detect CAD, its diagnostic performance in diabetics with suspected CAD is unknown. To compare the diagnostic performance of 64-slice MDCT between diabetics and non-diabetics with suspected CAD scheduled for invasive coronary angiography (ICA).
We enrolled one hundred and five diabetic patients (92 men, age 65 +/- 9 years, Group 1) and 105 non-diabetic patients (63 men, age 63+/-5 years, Group 2) with indication to ICA for suspected CAD undergoing coronary 64-slice MDCT before ICA.
In Group 1, the overall feasibility of coronary artery visualization was 93.8%. The most frequent artifact was blooming due to large coronary calcifications (54 artifacts, 67%). In Group 2, the overall feasibility was significantly higher vs. Group 1 (97%, p < 0.0001). In Group 1, the segment-based analysis showed a MDCT sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥50% luminal narrowing of 77%, 90%, 70%, 93% and 87%, respectively. In Group 2, all these parameters were significantly higher vs. Group 1. In the patient-based analysis, specificity, negative predictive value and accuracy were significantly lower in Group 1 vs. Group 2.
Although MDCT has high sensitivity for early identification of significant CAD in diabetics, its diagnostic performance is significantly reduced in these patients as compared to non-diabetics with similar clinical characteristics.
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