Atypical Angina Research Articles

Abstract 11134: Subclinical Coronary Plaque Burden in Asymptomatic Relatives of Patients With Documented Premature Coronary Artery Disease

Introduction: A family history of premature coronary artery disease (CAD) is a well-known risk factor for adverse coronary events with age of onset being inversely related to the degree of heritability. Hypothesis: We hypothesized that asymptomatic first degree relatives, of patients with premature CAD, suffer a high burden of subclinical coronary atherosclerosis. Methods: First degree relatives, aged 30-65 years, of patients with a documented coronary revascularization procedure before the age of 40 years, were invited to participate in the study. Participants were matched by age, sex and absence of a family history, with patients referred for coronary CT angiography (CTA) because of atypical angina or non-anginal chest pain. A pooled blinded analysis was performed. The main outcome measure was the number of plaque-affected coronary segments. Results: 88 relatives and 88 symptomatic controls underwent CTA. Treatment of hypertension and dyslipidemia tended to be more common among controls (p=0.06). 4 relatives reported vague symptoms of which none had angiographic signs of obstructive CAD (any luminal stenosis above 50%). The calculated SCORE risk among relatives was generally low (85% having a 10-year risk of ≤1%). Relatives had significantly (p=0.006) more affected segments than controls (0 segments: 29,6% vs. 48,9%, 1-2 segments: 27,3% vs. 31,8%, 3-5 segments: 23,9% vs. 11,4% and ≥6 segments: 19,3% vs. 8,0%). In a multivariable logistic regression analysis, the presence of any CAD (OR 3.16 (1.50;6.70)) as well as non-calcified plaques (OR 2.2 (1.14;4.26)), mixed plaques (OR 6.77 (2.7;16.98)) and calcified plaques (OR 2.34 (1.01;5.43)) were more frequent. Although increased, the presence of obstructive plaques, however, did not differ statistically significantly between relatives and controls (OR 2.58 (0.85;7.83)). Conclusions: Asymptomatic relatives of patients with premature CAD suffer a high coronary plaque burden even when compared with symptomatic patients with an a priori higher risk of CAD. Our results indicate a strong genetic component in the genesis of coronary atherosclerosis and, moreover, underline the limitations of current guidelines on prevention of CAD.

Quality-of-Life and Economic Outcomes of Assessing Fractional Flow Reserve With Computed Tomography Angiography: PLATFORM

BackgroundFractional flow reserve estimated using computed tomography (FFRCT) might improve evaluation of patients with chest pain. ObjectivesThe authors sought to determine the effect on cost and quality of life (QOL) of using FFRCT instead of usual care to evaluate stable patients with symptoms suspicious for coronary disease. MethodsSymptomatic patients without known coronary disease were enrolled into 2 strata based on whether invasive or noninvasive diagnostic testing was planned. In each stratum, consecutive observational cohorts were evaluated with either usual care or FFRCT. The number of diagnostic tests, invasive procedures, hospitalizations, and medications during 90-day follow-up were multiplied by U.S. cost weights and summed to derive total medical costs. Changes in QOL from baseline to 90 days were assessed using the Seattle Angina Questionnaire, the EuroQOL, and a visual analog scale. ResultsIn the 584 patients, 74% had atypical angina, and the pre-test probability of coronary disease was 49%. In the planned invasive stratum, mean costs were 32% lower among the FFRCT patients than among the usual care patients ($7,343 vs. $10,734 p < 0.0001). In the noninvasive stratum, mean costs were not significantly different between the FFRCT patients and the usual care patients ($2,679 vs. $2,137; p = 0.26). In a sensitivity analysis, when the cost weight of FFRCT was set to 7 times that of computed tomography angiography, the FFRCT group still had lower costs than the usual care group in the invasive testing stratum ($8,619 vs. $ 10,734; p < 0.0001), whereas in the noninvasive testing stratum, when the cost weight of FFRCT was set to one-half that of computed tomography angiography, the FFRCT group had higher costs than the usual care group ($2,766 vs. $2,137; p = 0.02). Each QOL score improved in the overall study population (p < 0.0001). In the noninvasive stratum, QOL scores improved more in FFRCT patients than in usual care patients: Seattle Angina Questionnaire 19.5 versus 11.4, p = 0.003; EuroQOL 0.08 versus 0.03, p = 0.002; and visual analog scale 4.1 versus 2.3, p = 0.82. In the invasive cohort, the improvements in QOL were similar in the FFRCT and usual care patients. ConclusionsAn evaluation strategy based on FFRCT was associated with less resource use and lower costs within 90 days than evaluation with invasive coronary angiography. Evaluation with FFRCT was associated with greater improvement in quality of life than evaluation with usual noninvasive testing. (Prospective Longitudinal Trial of FFRCT: Outcomes and Resource Impacts [PLATFORM]; NCT01943903)

Could the clinical interpretability of subgroups detected using clustering methods be improved by using a novel two-stage approach?

BackgroundRecognition of homogeneous subgroups of patients can usefully improve prediction of their outcomes and the targeting of treatment. There are a number of research approaches that have been used to recognise homogeneity in such subgroups and to test their implications. One approach is to use statistical clustering techniques, such as Cluster Analysis or Latent Class Analysis, to detect latent relationships between patient characteristics.Influential patient characteristics can come from diverse domains of health, such as pain, activity limitation, physical impairment, social role participation, psychological factors, biomarkers and imaging. However, such ‘whole person’ research may result in data-driven subgroups that are complex, difficult to interpret and challenging to recognise clinically.This paper describes a novel approach to applying statistical clustering techniques that may improve the clinical interpretability of derived subgroups and reduce sample size requirements.MethodsThis approach involves clustering in two sequential stages. The first stage involves clustering within health domains and therefore requires creating as many clustering models as there are health domains in the available data. This first stage produces scoring patterns within each domain. The second stage involves clustering using the scoring patterns from each health domain (from the first stage) to identify subgroups across all domains. We illustrate this using chest pain data from the baseline presentation of 580 patients.ResultsThe new two-stage clustering resulted in two subgroups that approximated the classic textbook descriptions of musculoskeletal chest pain and atypical angina chest pain. The traditional single-stage clustering resulted in five clusters that were also clinically recognisable but displayed less distinct differences.ConclusionsIn this paper, a new approach to using clustering techniques to identify clinically useful subgroups of patients is suggested. Research designs, statistical methods and outcome metrics suitable for performing that testing are also described. This approach has potential benefits but requires broad testing, in multiple patient samples, to determine its clinical value. The usefulness of the approach is likely to be context-specific, depending on the characteristics of the available data and the research question being asked of it.

What's the risk? Assessment of patients with stable chest pain.

In 2010, the National Institute for Heath and Clinical Excellence published guidelines for the management of stable chest pain of recent onset. Implementation has occurred to various degrees throughout the NHS; however, its effectiveness has yet to be proved. A retrospective study was undertaken to assess the impact and relevance of this guideline, comparing the estimated risk of coronary artery disease (CAD) with angiographic outcomes. Findings were compared with the recently published equivalent European guideline. A total of 457 patients who attended a Rapid Access Chest Pain Clinic were retrospectively reviewed. CAD risk was assessed according to NICE guidelines and patients were separated into typical, atypical and non-anginal chest pain groups. Risk stratification using typicality of symptoms in conjunction with NICE risk scoring and exercise tolerance testing was used to determine the best clinical course for each patient. The results include non-anginal chest pain – 92% discharged without needing further testing; atypical angina – 15% discharged, 40% referred for stress echocardiography, 35% referred for angiogram and significant CAD revealed in 8%; typical angina – 4% discharged, 19% referred for stress echocardiography, 71% referred for angiogram and 40% demonstrated CAD. Both guidelines appear to overestimate the risk of CAD leading to an excessive number of coronary angiograms being undertaken to investigate patients with typical or atypical sounding angina, with a low pick up rate of CAD. Given the high negative predictive value of stress echocardiography and the confidence this brings, there is much scope for expanding its use and potentially reduce the numbers going for invasive angiography.

Limitations of Chest Pain Categorization Models to Predict Coronary Artery Disease

We aimed to evaluate how chest pain categorization, currently used to assess the pretest probability of coronary artery disease (CAD), predicts the actual presence of CAD in a population of patients with stable symptoms. We studied 475 consecutive patients enrolled in the Evaluation of Integrated Cardiac Imaging for the Detection and Characterization of Ischemic Heart Disease study based on possible symptoms of CAD. Chest pain or discomfort was categorized as typical angina, atypical angina, or as nonanginal according to the guidelines. Exertional dyspnea and fatigue suspected to be angina equivalents were classified as atypical angina. Patients with a probability of CAD <20 or >90% based on age, gender, and symptoms were excluded. The end points of this substudy were significant CAD (defined by invasive coronary angiography as >50% reduction in lumen diameter in the left main stem or >70% stenosis in a major coronary vessel or 30% to 70% stenosis with fractional flow reserve ≤0.8), inducible myocardial ischemia at noninvasive stress imaging, and their association. Patients' symptoms had limited ability to predict the presence of significant CAD, global chi-square being 5.0. The inclusion of age increased global chi-square to 18.7 and gender increased it further to 51.1. Using inducible myocardial ischemia or the association of CAD with inducible ischemia as end points, the ability to predict these end points was again better for patient demographics than for patient symptoms. Thus, the ability of current models based on symptoms, age, and gender to predict the presence of CAD is mainly based on patient demographics as opposed to symptoms.

Evaluation of adiponectin and lipoprotein(a) levels in cardiac syndrome X.

Low adiponectin and high lipoprotein(a) [Lp(a)] levels are associated with endothelial dysfunction, atherosclerosis, and coronary artery disease. Cardiac syndrome X (CSX) is characterized by anginal symptoms, positive stress test, and documentation of normal epicardial coronary arteries with angiography. In this study we aimed to investigate the relationship between CSX and circulating levels of adiponectin and Lp(a). We enrolled 53 female patients with CSX and 33 patients as the control group. The diagnosis of CSX was made according to presence of angina, findings suggestive of ischemia during stress electrocardiography or myocardial perfusion scintigraphy, and documentation of normal coronary arteries in coronary angiography. The control group consisted of patients with atypical angina and normal stress electrocardiography test results. Both groups were matched in terms of hypertension, diabetes mellitus, and metabolic syndrome. Adiponectin levels were significantly decreased in patients with CSX (4.57 μg/ml vs. 13.18 μg/ml; p=0.001); however, Lp(a) levels were significantly increased (36.30 mg/dl vs. 7.24 mg/dl; p < 0.001). Low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) concentrations did not differ between the case group and the control group (p=0.14, p=0.62, p=0.64, respectively). There was no significant difference between groups in terms of age, body mass index, waist circumference hypertension, hyperlipidemia, diabetes mellitus, or metabolic syndrome. In multivariate analysis, Lp(a) and adiponectin were found to be independent predictors of CSX. An Lp(a) level of > 21 mg/dl had 84 % sensitivity and 96 % specificity {area under the curve (AUC)= 0.922, p < 0.0001, 95 % CI [0.842-0.970]} and an adiponectin level of ≤ 5.18 μg/ml also had 58.7 % sensitivity and 82.1 % specificity (AUC=0.726, p=0.0003, 95 % CI [0.609-0.823]) for detecting CSX. We detected low adiponectin and high Lp(a) levels in patients with CSX and these findings may be related to the microvascular injury in CSX.

Abstract 17557: Prevalence, Characteristics, and Early Treatment Strategies of Patients with Chronic Total Occlusions Undergoing Coronary Computed Tomography Angiography

Introduction: Data describing the prevalence, characteristics, and management of chronic total occlusions (CTO) in patients undergoing coronary computed tomography angiography (CCTA) have not been reported. Objectives: The purpose of this study was to determine the prevalence, characteristics, and treatment strategies of CTO identified by CCTA. Methods: We identified 23,745 patients who underwent CCTA for suspected coronary artery disease (CAD) from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry. Baseline clinical data were collected, and allocation to early coronary revascularization performed within 90 days of CCTA was determined. Multivariable logistic regression reporting odds ratios (OR) with 95% confidence intervals (95%CI) was performed. Results: Patients with CTO were older (64.7 ± 10.8 vs 57.2 ± 12.6 years, p&lt;0.001) and more often male (74.6% vs 54.1%, p&lt;0.001) compared with patients without CTO. The prevalence of CTO was 1.4% (342/23,745) in all patients and 6.2% in patients with obstructive CAD (≥50% stenosis). The presence of CTO was independently associated with male sex, smoking, hypertension, diabetes, age, and less common atypical angina (Table). Most CTO patients (61%) were treated medically, while 39% underwent coronary revascularization. In patients with severe CAD (≥70% stenosis), CTO independently predicted revascularization by CABG (OR 3.06, 95%CI: 1.88-4.98, p&lt;0.001) but not by PCI (p=0.08). Conclusions: CTOs are not uncommon in a contemporary CCTA population and are associated with age, gender, angina status and CAD risk factors. Most individuals with CTO undergoing CCTA are managed medically with higher rates of surgical revascularization in patients with versus without CTO.

Abstract 166: Improved Patterns of Diagnostic Management of Patients Using a Personalized Gene Expression Score Among Matched Cohorts of Patients Presenting to the Cardiologist with Symptoms of Suspected Obstructive Coronary Artery Disease: Results from the Understanding Clinician Utility-Cardiology Trial

Background: Better methods are needed for the evaluation of stable, non-acute patients presenting with symptoms suggestive of obstructive coronary artery disease (CAD). A previously validated blood-based, gene expression diagnostic test has a negative predictive value of 96% in ruling out the diagnosis of obstructive CAD in non-diabetic patients without a history of revascularization or myocardial infarction. Objective: Using a matched cohort design, the objective of this study is to evaluate the patterns of care by a cardiologist in the diagnostic management of ambulatory care patients presenting with symptoms suggestive of obstructive CAD both in usual care and after the incorporation of a personalized medicine, gene expression score (GES). Methods: The Understanding Clinician Utilization-Cardiology Trial is a retrospective, matched cohort study evaluating patterns of care for patients without a history of CAD who were referred to cardiology for further work up of chest pain and/or related symptoms. GES patients were matched to historical non-GES patients by clinical factors (gender, age ±5 years, presenting symptoms). GES results were predefined as low (GES ≤15) or elevated (GES &gt;15). The primary outcome was a comparison of management decisions between the GES cohort and the matched control group using the Fisher Exact Test. Results: For primary endpoint analysis, 264 patients were eligible (132 GES patients, 132 matched controls): 146 (55%) female, median age of 51 years, and median GES of 12 (range 1-40). The GES and control groups had similar demographics and were well matched at baseline. Symptoms were evaluated as typical angina or atypical angina in 52% (129/246) and 48% (117/246) of patients, respectively. Overall, the cardiologist deferred further diagnostic testing in a greater number of patients in the GES cohort: 42% (56/132) of GES patients vs. 6% (8/132) of control patients had no further testing (p&lt;0.001). Within the GES cohort, a low GES was noted in 58% (77/132) of patients, and the low GES patient group had more patients who did not proceed to further diagnostic testing compared to the elevated GES patient group, 39/77 (51%) vs. 17/55 (33%), respectively(p=0.03). Notably, there was a highly significant difference in the number of patients who did not proceed to further diagnostic testing in the low GES group (39/77) vs. the matched control group (4/77) (p&lt;0.0001). Conclusion: Gene expression testing influenced the cardiologist’s diagnostic work up of patients. There was a statistically significant decrease in additional diagnostic tests ordered in the GES cohort compared to a matched historical control group of patients. In conclusion, GES helped identify patients who did not require further diagnostic testing, and incorporating the GES into cardiac diagnostic clinical decision making may improve the efficiency of care in ruling out the diagnosis of obstructive CAD.

TCTAP C-171 Intercoronary Communication in a Patient with Non-obstructive Coronary Arteries

### Patient initials or identifier number SM ### Relevant clinical history and physical exam This is a case of a 47-year-old male admitted in a foreign country due to regular and progressive atypical angina for two weeks. It was described as 5/10 in the visual pain scale, squeezing and non-

Myocardial perfusion scintigraphy: interpretation of a normal scan

Myocardial perfusion scintigraphy: interpretation of a normal scan

Philippine Heart Association-Acute Coronary Syndrome Registry- 2 Year Results

BACKGROUND: An acute coronary syndrome (ACS) registry was initiated by the Philippine Heart Association and launched in November 2011, enrolling 1,939 patients for its preliminary 2-year enrollment period. RESULTS: Results showed that ACS occurred predominantly in males (67%), and patients had a median age of 61 years. Hypertension (77.1%), diabetes (39%) and smoking history (33.4%) were the common risk factors for ACS. A significant number of post-menopausal women (30%) suffered from ACS. Chest pain or heaviness (74.5%) was the common presenting symptom, while atypical presentation or angina equivalents and aborted sudden cardiac death occurred in 24.4% and 0.6%, respectively. Non-ST elevation myocardial infarction was the most common spectrum of ACS (49%), followed by ST elevation myocardial infarction (36%) and unstable angina (14.5%). The median time interval from symptom to emergency room was 360 minutes or 16 hours. Time from Door to Needle and Door to Balloon was 60 minutes and 180 minutes, respectively. There was good adherence (&gt;85%) to class 1 recommended drugs, namely beta blockers, angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers, statins, and dual anti-platelet therapy. There was low adherence to discharge lifestyle counseling and referral to cardiac rehabilitation program. The mortality and bleeding rates were 7.8% and 1.15%, respectively. KEYWORDS: Acute Coronary Syndrome, Unstable Angina, Non ST Elevation Myocardial Infarction, ST Elevation Myocardial Infarction.

False positive results of SPECT - we should minimize the unnecessary referrals to invasive coronary angiography

Purpose: False positive (FP) results are common in single-photon emission computed tomography (SPECT) performed for obstructive coronary artery disease (OCAD) investigation. It is important to discriminate whether an ischemic result of SPECT is a FP, to avoid unnecessary referrals for invasive coronary angiography (ICA). We determined the clinical factors that were independently associated with a FP SPECT result. Methods: We analyzed a cohort of patients referred for ICA for stable coronary artery disease diagnosis, based on clinical judgment and a SPECT positive for ischemia, in a single tertiary-care center (2006-2011). Traditional and nontraditional coronary artery disease risk factors, modified Framingham risk score (FRS), symptoms, pre-test (SPECT) probability of OCAD, left ventricular ejection fraction and ICA results were assessed. OCAD was defined as any luminal narrowing ≥70%, or ≥50% for the left main artery. A FP SPECT was defined as reversible stress-induced perfusion defect and no OCAD. The predictors of a FP result were determined by the chi-square, exact Fisher and t-student tests when appropriate, and multivariate analysis (logistic regression). The discriminatory power for a FP result, of a model based on those predictive factors, was assessed by the area under the ROC curve (AUC) analysis. Results: 960 patients were included: 66.6±9.9 years, 58.1% male, mean 10-year Framingham risk 19.0%; 45.9% typical angina and 17.5% atypical angina; 55% high pre-test probability of OCAD; 13.6% depressed left ventricular ejection fraction (<55%). Globally, 51.0% of SPECT were FP results. The factors independently associated with a FP SPECT were: absence of severe angina (OR 6.1, 95% CI 2.1-17.4), absence of typical angina (OR 4.2, 95% CI 2.9-5.9), presence of atypical angina (OR 2.8, 95% CI 1.6-5.0), normal left ventricular ejection fraction (≥55%) (OR 2.5, 95% CI 1.7-3.5), female gender (OR 2.4, 95% CI 1.8-3.4) and lower FRS (OR 1.2, 95% CI 1.1-1.2), (all p<0.05). A model considering these factors together had good discriminatory power for predicting a FP result: AUC 0.80, 95% CI 0.78-0.83. Conclusions: Half of SPECT were FP in a population of patients referred for ICA following clinical judgment and a SPECT positive for ischemia. When analyzed together, the absence of severe angina/typical angina, the presence of atypical angina, normal left ventricular ejection fraction, female gender and lower FRS have good power for discriminating a FP result. These parameters should be given more relevance in order to avoid some unnecessary referrals for ICA.

False positive results of treadmill exercise ECG - we should minimize the unnecessary referrals to invasive coronary angiography

Purpose: False positive (FP) results are common in treadmill exercise ECG testing (TMT) performed for obstructive coronary artery disease (OCAD) screening. It is important to discriminate whether an ischemic response in TMT is a FP result, to avoid unnecessary referrals for invasive coronary angiography (ICA). We determined the clinical factors that were independently associated with a TMT FP result. Methods: We analyzed a cohort of patients referred for ICA for stable coronary artery disease diagnosis, based on clinical judgment and a TMT positive for ischemia, in a single tertiary-care center (2006-2011). Traditional and nontraditional coronary artery disease risk factors, modified Framingham risk score, symptoms, pre-test (TMT) probability of OCAD, left ventricular ejection fraction and ICA results were assessed. OCAD was defined as any luminal narrowing ≥70%, or ≥50% for the left main artery. A FP TMT result was defined as an ischemic response (2006 TMT European Society of Cardiology guidelines) and no OCAD. The predictors of a FP result were determined by the chi-square, exact Fisher and t-student tests when appropriate, and multivariate analysis (logistic regression). The discriminatory power for a FP result, of a model based on those predictive factors, was assessed by the area under the ROC curve (AUC) analysis. Results: 1243 patients were included: 65.2±9.9 years, 63.0% male, mean 10-year Framingham risk 17.8%; 51.1% typical angina and 20.1% atypical angina; 65.4% high pre-test probability of OCAD; 4.3% depressed left ventricular ejection fraction (<55%). Globally, 51.6% of TMT were FP results. The factors independently associated with a FP TMT were: absence of severe angina (OR 22.0, 95% CI 5.3-91.2), presence of atypical angina (OR 17.3, 95% CI 9.4-31.6), absence of angina (OR 3.8, 95% CI 2.9-5.2), female gender (OR 2.4, 95% CI 1.8-3.3), non-smoking (OR 2.1, 95% CI 1.4-3.0), absence of diabetes (OR 1.5, 95% CI 1.1-2.0) and younger age (OR 1.1, 95% CI 1.0-1.1), (all p<0.05). A model considering these factors together had good discriminatory power for predicting a FP result: AUC 0.80, 95% CI 0.78-0.83. Conclusions: Half of positive TMT were FP in a population of patients referred for ICA following clinical judgment and a TMT positive for ischemia. When analyzed together, the absence of angina/severe angina, the presence of atypical angina, female gender, non-smoking, absence of diabetes and younger age have good power for discriminating a FP result. These parameters should be given more relevance in order to avoid some unnecessary referrals for ICA.

GW24-e1809 Clinical analysis of 37 cases with coronary myocardial bridge

ObjectivesTo analysis clinical characteristics, follow-up and treatment in patients with coronary myocardial bridge.MethodsFrom August 2006 to December 2011, coronary angiography (CAG) was done in 1567 cases by Judkins method and...

Critical stenosis left main coronary artery in 39-year-old woman treated with percutaneous angioplasty

Isolated critical stenosis of left main coronary artery (LMCA) due to atherosclerosis is very rare and affects about 0.2% of patients. We present the case of a 39-year-old, non-smoker women with risk factors for diseases of the cardiovascular system in the form of hypercholesterolaemia and hypertension, in addition to positive family history and chronic oral contraception. Sick from occurring since atypical angina masked depressive symptoms, with a critical stenosis of LMCA and little suggestive symptoms of ischaemia because of the existing collateral circulation.

Presence of Angina Pectoris Is Related to Extensive Coronary Artery Disease in Diabetic Patients

Due to sensorial autonomic neuropathy, the type and severity of angina pectoris in patients with diabetes mellitus (DM) may be rather different from the type and severity of angina pectoris in patients without DM. The aim of the study was to understand if angina pectoris is related to extensive coronary artery disease (CAD) in patients with DM. The study included 530 patients with DM who underwent coronary angiography at our center in 2009 and 2010. Patients were divided into 4 groups according to type of chest pain: group 1, noncardiac chest pain or no pain; group 2, angina equivalent; group 3, atypical angina; and group 4, typical angina. All angiograms were re-evaluated and Gensini scores were calculated. Three-vessel disease was diagnosed in the presence of stenosis >50% in all 3 coronary artery systems. There were no statistically significant differences between the groups with regard to age, sex, systolic or diastolic blood pressures, body mass index, creatinine clearance, or lipid profile. Fasting blood glucose was significantly higher in group 4 than in group 2. Gensini scores were not statistically different between groups 1 and 2 or between groups 3 and 4; however, the scores for groups 3 and 4 were higher than the score for either group 1 or group 2. Prevalence of 3-vessel disease was significantly higher in groups 3 and 4 compared with the other groups. The presence of angina pectoris was related to extensive CAD in patients with DM. The extent of CAD was not correlated with the type of angina (typical or atypical).

SAT0084 Chest Pain is not Associated with Coronary Atherosclerosis in Patients with Rheumatoid Arthritis and Ankylosing Spondylitis

BackgroundDuring cardiovascular (CV) risk stratification in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS), it can be difficult to distinguish between chest pain related to coronary atherosclerosis (CA), or...

The Clinical Utility of Gene Expression Testing on the Diagnostic Evaluation of Patients Presenting to the Cardiologist With Symptoms of Suspected Obstructive Coronary Artery Disease

Accurate, noninvasive evaluation for obstructive coronary artery disease (CAD) remains challenging and inefficient. In this study, 171 patients presenting with stable chest pain and related symptoms without a history of CAD were referred to 6 cardiologists for evaluation. In the prospective cohort of 88 patients, the cardiologist's diagnostic strategy was evaluated before and after gene expression score (GES) testing. The GES is a validated, quantitative blood-based diagnostic test measuring peripheral blood cell expression levels of 23 genes to determine the likelihood of obstructive CAD (at least 1 vessel with ≥ 50% angiographic coronary artery stenosis). The objective of the study was to measure the effect of the GES on diagnostic testing using a pre/post study design. There were 83 prospective patients evaluable for study analysis, which included 57 (69%) women, mean age 53 ± 11 years, and mean GES 12.5 ± 9. Presenting symptoms were classified as typical angina, atypical angina, and noncardiac chest pain in 33%, 60%, and 7% of patients (n = 27, 50, and 6), respectively. After GES, changes in diagnostic testing occurred in 58% of patients (n = 48, P < 0.001). Of note, 91% (29/32) of patients with decreased testing had low GES (≤ 15), whereas 100% (16/16) of patients with increased testing had elevated GES (P < 0.001). A historical cohort of 83 patients, matched to the prospective cohort by clinical factors, had higher diagnostic test use compared with the post-GES prospective cohort (P < 0.001). In summary, the GES showed clinical utility in the evaluation of patients with suspected obstructive CAD presenting to the cardiologist's office.

A Long-Term Prognostic Value of CT Angiography and Exercise ECG in Patients With Suspected CAD

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). 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. 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. 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 CTAwas 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. 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.

140 RISK ASSESSMENT OF STABLE CHEST PAIN PATIENTS AS PER NICE GUIDELINES FROM A RAPID ACCESS CHEST PAIN CLINIC CORRELATING ESTIMATED RISK OF CORONARY ARTERY DISEASE AND OUTCOMES BY ANGIOGRAPHY

IntroductionPatients presenting with symptoms suggestive of stable angina are routinely referred by their GP to a Rapid Access Chest Pain Clinic (RACPC) to assess whether there may be underlying coronary...