Exclusion Of Coronary Artery Disease Research Articles

Imaging in Infective Endocarditis-Current Opinions and Trends in Cardiac Computed Tomography.

Infective endocarditis is a rare disease with an increasing incidence and an unaltered high mortality rate, despite medical development. Imaging plays an integrative part in the diagnosis of infective endocarditis, with echocardiography as the initial diagnostic test. Research data in the utility of cardiac computed tomography (CCT) in the diagnostic algorithm of IE are rising, which indicates its importance in detection of IE-related lesion along with the exclusion of coronary artery disease. The latest 2023 European Society of Cardiology Guidelines in the management of IE classified CCT as class of recommendation I and level of evidence B in detection of both valvular and paravalvular lesions in native and prosthetic valve endocarditis. This review article provides a comprehensive and contemporary review of the role of CCT in the diagnosis of IE, the optimization of acquisition protocols, the morphology characteristics of IE-related lesions, the published data of the diagnostic performance of CCT in comparison to echocardiography as the state-of-art method, as well as the limitations and future possibilities.

Evaluation and Diagnosis of Acute Chest Pain

Acute chest pain is a frequent cause of visits to emergency departments. As the major etiologies of such pain include life-threatening acute myocardial infarction, aortic dissection, and pulmonary embolism, prompt diagnosis and management are essential. After exclusion of coronary artery disease, other cardiac causes must be considered. In this review, we discuss the diagnosis of acute chest pain with a focus on clinical symptoms and the initial examination.

Association of plasma propionate concentration with coronary artery disease in a large cross-sectional study.

Microbiome has been linked to the pathogenesis of coronary artery disease (CAD) but data providing direct evidence for an association of short-chain fatty acids (SCFA) with CAD are lacking. This study aimed to evaluate the role of propionate, the most important SCFA in patients with CAD. We performed a cross-sectional study enrolling patients admitted for invasive coronary angiography in two university hospitals in Germany. Patients with known or suspected CAD and risk factors for cardiovascular disease were prospectively recruited. Blood sampling was performed after overnight fasting and before invasive procedures. Measurement of propionate was performed by liquid chromatography. The study included 1,253 patients (median [IQR], 67 [58-76] years; 799 men [64%]). A total of 739 had invasively confirmed CAD with at least one coronary artery stenosis ≥50% and 514 had exclusion of CAD. CAD patients had significant lower levels of propionate (median 5.75 μM, IQR, 4.1-7.6) compared to the non-CAD groups 6.53 μM (4.6-8.6, p < 0.001). Multivariate linear regression analysis revealed an odds ratio of 0.94 (CI 0.90-0.98, p = 0.002) for propionate as predictor of CAD. The odds ratio was further decreased to 0.45 (CI 0.31-0.65, p < 0.001) when comparing patients in the lowest quartile of propionate with those with higher levels of propionate. The study provides large-scale in vivo data for the association of propionate to manifest coronary artery disease, independent of other traditional cardiovascular risk factors.

676 A PITFALL IN ECHOGRAPHIC DIAGNOSIS OF ABDOMINAL AORTIC ANEURYSM: WHEN PARA-AORTIC LYMPH NODES REQUIRE ATTENTION

Abstract Image focus A 65-year-old women was scheduled for coronary angiography during the pre-surgery evaluation because of an abdominal aortic aneurysm (AAA) detected at ultrasound (Figure). The patient referred worsening dyspnoea and asthenia in the last few months, associated with atypical chest pain. Because of these symptoms and taking into account that AAA patients are at very high cardiovascular risk, exclusion of coronary artery disease seemed appropriate. At admission, patient showed enlarged lymph nodes at cervical and inguinal region. In the suspicion of a malignant cancer, a contrast enhanced computed tomography was scheduled, showing an increase in para-aortic, inguinal, cervical and axillary lymph nodes size in absence of the AAA (Figure). After blood tests and an haematologic consultation, a final diagnosis of chronic myeloid leukaemia was made. The Echo-colour Doppler is the first line imaging test for the diagnosis of AAA. However, in some cases it might be not sufficient. Para-aortic lymphadenopathy should be considered as a possible pitfall in the differential diagnosis of abdominal aortic aneurysm.

Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial

IntroductionIdentifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool...

Sildenafil citrate for the treatment of patients with cardiovascular diseases with exclusion of coronary artery disease and hypertrophic subaortic stenosis

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Soluble ST2 Receptor: Biomarker of Left Ventricular Impairment and Functional Status in Patients with Inflammatory Cardiomyopathy.

Introduction: Inflammatory cardiomyopathy (ICM) frequently leads to myocardial fibrosis, resulting in permanent deterioration of the left ventricular function and an unfavorable outcome. Soluble suppression of tumorigenicity 2 receptor (sST2) is a novel marker of inflammation and fibrosis in cardiovascular tissues. sST2 was found to be helpful in predicting adverse outcomes in heart failure patients with reduced ejection fraction. The aim of this study was to determine the association of sST2 plasma levels with cardiac magnetic resonance (CMR) and echocardiography imaging features of left ventricular impairment in ICM patients, as well as to evaluate the applicability of sST2 as a prognosticator of the clinical status in patients suffering from ICM. Methods: We used plasma samples of 89 patients presenting to the Heart Center Leipzig with clinically suspected myocardial inflammation. According to immunohistochemical findings in endomyocardial biopsies (EMB) conducted in the context of patients’ diagnostic work-up, inflammatory cardiomyopathy was diagnosed in 60 patients (ICM group), and dilated cardiomyopathy in 29 patients (DCM group). All patients underwent cardiac catheterization for exclusion of coronary artery disease and CMR imaging on 1.5 or 3 Tesla. sST2 plasma concentration was determined using ELISA. Results: Mean plasma concentration of sST2 in the whole patient cohort was 45.8 ± 26.4 ng/mL (IQR 27.5 ng/mL). In both study groups, patients within the highest quartile of sST2 plasma concentration had a significantly lower left ventricular ejection fraction (LV-EF) compared to patients within the lowest sST2 plasma concentration quartile (26 ± 11% vs. 40 ± 13%, p = 0.05 for ICM and 24 ± 13% vs. 51 ± 10%, p = 0.004 for DCM). sST2 predicted New York Heart Association (NYHA) class III/IV at 12 months follow-up more efficiently in ICM compared to DCM patients (AUC 0.85 vs. 0.61, p = 0.02) and was in these terms superior to NT-proBNP and cardiac troponin T. ICM patients with sST2 plasma concentration higher than 44 ng/mL at baseline had a significantly higher probability of being assigned to NYHA class III/IV at 12 months follow-up (hazard ratio 2.8, 95% confidence interval 1.01–7.6, log rank p = 0.05). Conclusion: Plasma sST2 levels in ICM patients reflect the degree of LV functional impairment at hospital admission and predict functional NYHA class at mid-term follow-up. Hence, ST2 may be helpful in the evaluation of disease severity and in the prediction of the clinical status in ICM patients.

Painful left bundle branch block: A syndrome with a particular clinical significance

The development of angina in the setting of new-onset left bundle branch block (LBBB) that resolves at the same time with the disappearance of LBBB, without coexistent myocardial ischemia, denotes the painful LBBB syndrome. In this illustrative case report we describe a young male patient with painful LBBB syndrome. The LBBB was rate-dependent occurring during exercise and the patient was successfully treated with bisoprolol. We also provide a concise review of the literature and we briefly discuss the diagnosis and management of this clinical entity.<Learning objective: Painful left bundle branch block syndrome is a rare clinical entity, that is possibly underdiagnosed. The exclusion of coronary artery disease in a patient with angina pectoris occurring simultaneously with the development of left bundle branch block should raise the suspicion of this syndrome.>

Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation

Coronary CT angiography (CTA) is currently considered a reliable method to exclude obstructive coronary artery disease (CAD) before valvular heart surgery in patients with low pretest probability. However, its role in excluding obstructive CAD before transcatheter aortic valve implantation (TAVI) is less well established. Single-center retrospective study where patients with severe symptomatic aortic stenosis underwent both CTA and invasive coronary angiography (ICA) as part of TAVI planning. CTA exams were conducted on a 64-slice dual source scanner, with a median interval of 45 days to ICA (IQR 25–75 [13–82]). In both tests, obstructive CAD was defined as a ≥50% stenosis in an epicardial vessel ≥2 mm diameter. Per-patient, per-vessel and per-proximal segment analyses were conducted, excluding and including non-evaluable segments. The study included 200 patients (120 women, mean age 83 ± 6 years). The prevalence of obstructive CAD on ICA was 35.5% (n = 71). On a per-patient analysis (assuming non-evaluable segments as stenotic), CTA showed sensitivity of 100% (95% CI, 95–100%), specificity of 42% (95% CI, 33–51%), and positive and negative predictive values of 48% (95% CI, 44–51%) and 100% (95% CI, 92–100%), respectively. CTA was able to exclude obstructive CAD in 54 patients (27%), in whom ICA could have been safely withheld. Despite the high rate of inconclusive tests, pre-procedural CTA is able to safely exclude obstructive CAD in a significant proportion of patients undergoing TAVI, possibly avoiding the need for ICA in roughly one quarter of the cases.

P815Tako-Tsubo Cardiomyopathy: clinical correlations of typical and atypical left ventricular contraction patterns

Abstract Background Takotsubo cardiomyopathy (TCM) is diagnosed in 1–2% of all patients presenting with acute coronary syndrome (ACS). Clinical differences in individuals presenting with either the typical (apical) or atypical (midventricular, basal and focal) localization of left ventricular contraction abnormalities are not well understood. Methods We retrospectively analyzed 102 consecutive patients diagnosed with TCM based on clinical presentation, coronary angiography, and laevocardiography. Patients with different contraction abnormality patterns were compared regarding sex, clinical presentation, trigger for TCM, LV-function and LV enddiastolic pressure (LVEDP) as well as coronary artery disease. Results Of all TCM 102 patients, 69 (68%) presented with the typical pattern of apical contraction abnormality. 33 patients (32%) had an atypical pattern: 22 (22%) with the midventricular type, 2 (2%) with the basal type and 9 (9%) with a focal type. There was no difference in sex distribution among the different types of TCM (female: typical 86% vs atypical 85% p=0.83). Presentation as a ST-elevation ACS was more common in patients with atypical compared to typical TCM (21% vs. 17%; p=0.85), but without statistical significance. Cardiogenic shock (typical 6% vs atypical 3%; p=0.91) as well as intra-hospital death (typical 3% vs atypical 3%; p=0.56) were rare in both types. A trigger was not more common in patients with typical TCM (58% vs atypical 55%; p=0.91). The trigger was more often physical in typical (73%) and atypical TCM (78%) than psychological, but the distribution did not differ between the two types (p=0.92). 83.6% of the patients showed an impaired LV-EF. Median LV-EF in patients with typical TCM (35% (IQR 25–40)) tended to be lower than in patients with atypical TCM (40% (IQR 25–40); p=0.63; LV-EF ≤30% typical TCM 45% vs. atypical TCM 39%; p=0.75). In 72% (73/102) of the patients the LVEDP was determined. In 75% (55/73) the LVEDP was elevated (&gt;15mmHg). LVEDP tended to be more often elevated in patients with typical TCM (83% vs. atypical 52%; p=0.11). Extent of coronary artery disease did not differ in the different types of TCM. Coronary stenosis &gt;50% was rare (typical TCM 20% vs atypical TCM 9%; p=0.26), whereas exclusion of coronary artery disease was common in both types (typical TCM 71%; atypical TCM 76%; p=0.79). Conclusion While an apical contraction anomaly is the most common type of presentation in TCM, atypical contraction patterns are found in 32% of the patients. Overall, psychological triggers are not found as frequently in TCM as previously described. Patients with typical and atypical TCM do not differ in clinical presentation, LV-EF, LVEDP and extent of coronary artery disease.

TCT-201 Does a Coronary Calcium Score Zero Reliably Rule Out Coronary Artery Disease in Low-to-Intermediate Risk Patients? A Coronary CTA Study

Coronary calcium score zero ( <1.0 Agatston Units [AU]) is advocated for a safe exclusion of coronary artery disease (CAD) by the American Heart Association. Coronary computed tomography angiography (CTA) enables the detection of low-attenuation fibroatheroma and high-risk plaque, representing

Assessment of acute myocarditis by cardiac magnetic resonance imaging: Comparison of qualitative and quantitative analysis methods

BackgroundTo compare cardiac magnetic resonance (CMR) qualitative and quantitative analysis methods for the noninvasive assessment of myocardial inflammation in patients with suspected acute myocarditis (AM). MethodsA total of 61 patients with suspected AM underwent coronary angiography and CMR. Qualitative analysis was performed applying Lake-Louise Criteria (LLC), followed by quantitative analysis based on the evaluation of edema ratio (ER) and global relative enhancement (RE). Diagnostic performance was assessed for each method by measuring the area under the curves (AUC) of the receiver operating characteristic analyses. The final diagnosis of AM was based on symptoms and signs suggestive of cardiac disease, evidence of myocardial injury as defined by electrocardiogram changes, elevated troponin I, exclusion of coronary artery disease by coronary angiography, and clinical and echocardiographic follow-up at 3 months after admission to the chest pain unit. ResultsIn all patients, coronary angiography did not show significant coronary artery stenosis. Troponin I levels and creatine kinase were higher in patients with AM compared to those without (both P < .001). There were no significant differences among LLC, T2-weighted short inversion time inversion recovery (STIR) sequences, early (EGE), and late (LGE) gadolinium-enhancement sequences for diagnosis of AM. The AUC for qualitative (T2-weighted STIR 0.92, EGE 0.87 and LGE 0.88) and quantitative (ER 0.89 and global RE 0.80) analyses were also similar. ConclusionsQualitative and quantitative CMR analysis methods show similar diagnostic accuracy for the diagnosis of AM. These findings suggest that a simplified approach using a shortened CMR protocol including only T2-weighted STIR sequences might be useful to rule out AM in patients with acute coronary syndrome and normal coronary angiography.

Use of coronary computed tomography angiography in clinical practice - single centre experience in Switzerland in light of current recommendations based on pretest probability considerations.

Coronary computed tomography angiography (CCTA) is recommended as a first-line option for the exclusion of coronary artery disease in patients with low to intermediate (15&ndash;50%) pretest probability. We aimed to study the use of CCTA in clinical practice in a single centre in Switzerland in light of this recommendation. In 523 consecutive patients (age 56 &plusmn; 13 years, 48% females) undergoing CCTA during a period of 2 years, the pretest probability of coronary artery disease was assessed using the revised Diamond-Forrester model (CAD consortium score). In patients who had invasive coronary angiography following CCTA, angiographic findings and the consequences regarding management are reported. The majority of patients (n = 316; 60%) had a pretest probability &lt;15%, 188/523 (36%) had a pretest probability between 15 and 50%, and 19/523 (4%) had a pretest probability &gt;50%. The prevalences of coronary artery disease (&ge;50% lumen diameter reduction) by CCTA in patients with pretest probability &lt;15%, 15&ndash;50%, and &gt;50% were 25/316 (8%), 45/188 (24%) and 8/19 (42%), respectively. In 438/523 patients (84%), a CCTA scan showing no coronary artery disease represented the final diagnostic step. In patients undergoing invasive coronary angiography (n = 59, age 58 &plusmn; 9 years, 88% with coronary artery disease by CCTA), coronary artery disease was found in 47/59 (80%) patients and 36/59 (61%) patients underwent revascularisation. The prevalences of coronary artery disease by invasive coronary angiography in patients with pretest probability &lt;15%, 15&ndash;50%, and &gt;50% were 14/21 (67%), 28/32 (88%) and 5/6 (83%). The present data suggest that the currently used pretest probability model is still imperfect and that guideline recommendations regarding pretest probability use for the selection of CCTA candidates are not followed completely. Still, in more than 80% of patients coronary artery disease could be excluded by CCTA, while CCTA also detected a significant number of patients with coronary artery disease in the low pretest probability population. Thus, the data suggest a very judicious use of CCTA as a gatekeeper for invasive coronary angiography in current practice.

CTCA for detection of significant coronary artery disease in routine TAVI work-up : Asystematic review and meta-analysis.

Transcatheter aortic valve implantation (TAVI) has evolved to standard treatment of severe aortic stenosis in patients with an intermediate to high surgical risk. Computed tomography coronary angiography (CTCA) could partially replace invasive coronary angiography to diagnose significant coronary artery disease in the work-up for TAVI. A literature search was performed in MEDLINE and EMBASE for papers comparing CTCA and coronary angiography in TAVI candidates. The primary endpoint was the diagnostic accuracy of CTCA, compared to coronary angiography, for detection of significant (>50% diameter stenosis) coronary artery disease, measured as sensitivity, specificity, positive—(PPV) and negative predictive value (NPV). Seven studies were included, with a cumulative sample size of 1,275 patients. The patient-based pooled sensitivity, specificity, PPV and NPV were 95, 65, 71 and 94% respectively. Quality assessment revealed excellent and good quality in terms of applicability and risk of bias respectively, with the main concern being patient selection. In conclusion, on the basis of a significance cut-off value of 50% diameter stenosis, CTCA provides acceptable diagnostic accuracy for the exclusion of coronary artery disease in patients referred for TAVI. Using the routinely performed preoperative computed tomography scans as a gatekeeper for coronary angiography could decrease additional coronary angiographies by 37% in this high-risk and fragile population.Electronic supplementary materialThe online version of this article (10.1007/s12471-018-1149-6) contains supplementary material, which is available to authorized users.

Approximation of the Incidence of Myocarditis by Systematic Screening With Cardiac Magnetic Resonance Imaging

ObjectivesThis study sought to obtain an approximation of the true incidence of myocarditis by systematic screening of patients at risk using cardiac magnetic resonance imaging (CMR) in a tertiary care center. BackgroundUnderdiagnosis of myocarditis and resulting uncertainty about its incidence remain a clinical dilemma. The authors hypothesized that systematic screening of patients presenting with angina-like symptoms, elevated troponin T, and no significant coronary artery disease using CMR will provide an approximation of the true incidence of myocarditis. MethodsThe authors performed a retrospective chart review of patients presenting with angina-like symptoms and elevated high-sensitivity troponin T (TnT-hs ≥14 ng/l) in 2015 and 2016. During the year 2015, only patients with elevated TnT-hs, no significant coronary artery disease, and moderate-to-high clinical likelihood of myocarditis underwent CMR. Starting in 2016, CMR was obtained in patients with similar presentation, but independent of clinical likelihood of myocarditis. ResultsA total of 1,788 patients (74% male, age 69 ± 14 years) qualified for our analysis. In 2015, 521 patients presented with angina-like symptoms and TnT-hs elevation. In 2016, the number increased to 1,267 patients. Although in the year 2015, a total of 4 of 88 (5%) CMRs were positive for myocarditis, the percentage of positive CMRs doubled (26 of 199; 13%; p = 0.03) in 2016. ConclusionsA novel diagnostic screening algorithm led to a 6.3-fold increase of the incidence of myocarditis in our hospital. Furthermore, the percentage of CMRs positive for myocarditis doubled, supporting the diagnostic value of this method. Considering the potentially lethal adverse events of myocarditis if left untreated, we recommend a low threshold for the use of CMR in patients with angina-like symptoms and elevated TnT-hs after exclusion of coronary artery disease.

Impact of Diabetes Duration on the Extent and Severity of Coronary Atheroma Burden in Type 2 Diabetic Patients : Evaluation by Coronary CT Angiography

Aim of the work: this study aimedto explore the association between diabetes duration on both the extent and severity of coronary atheroma burden using coronary computed tomography angiography (CCTA) in type 2 diabetic patients. Patients and methods: we analyzed 105 symptomatic type 2 diabetic patients without known CAD who underwent CCTA from August 2016 to June 2017. Patients were categorized into two groups according to the duration of diabetes: < 10 years, and ≥ 10 years. Stenosis by CCTA was scored as none (0%), non-obstructive (1–49%), or obstructive (≥50%) for each coronary artery segment. For these patients, we compared the prevalence, extent, and severity of CAD, including coronary artery calcium score (CACS), atheroma burden obstructive score (ABOS), segment involvement score (SIS), segment stenosis score (SSS) and syntax score. Results: patients with longer duration of type 2 diabetes possessed higher rates of obstructive CAD. Patients with longer duration of diabetes also manifested greater degree of CACS, ABOS, SIS, SSS and syntax score (P < 0.001 for all). Conclusion: in symptomatic type 2 diabetic patients, longer diabetes duration was associated with a higher prevalence, extent, and severity of CAD so, increased risk of developing atherosclerotic cardiovascular disease including major events as myocardial infarction or even sudden cardiac death. INTRODUCTION Reducing atherosclerotic cardiovascular disease (ASCVD) burden in diabetes mellitus (DM) is a major clinical imperative that should be prioritized to reduce premature death, improve quality of life and lessen individual and economic burdens of associated morbidities, decreased work productivity, and high cost of medical care [1]. Atherosclerotic cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus, especially in those with type 2 diabetes mellitus in whom it typically occurs 14.6 years earlier [2], with greater severity, and with more diffuse distribution than in individuals without diabetes mellitus [3]. Furthermore, about two-thirds of deaths in people with diabetes mellitus are attributable to cardiovascular disease: of these, ≈ 40% are from ischemic heart disease, 15% from other forms of heart disease, principally congestive heart failure, and ≈10% from stroke. Among those with diabetes mellitus, excess risks of death from any cause and of ASCVD mortality are particularly prominent in those with younger age, higher burden of glycaemia, and greater renal complications, in comparison with those without [4]. Although the incidences of diabetes mellitus–related complications including cardiovascular disease have decreased over the past 2 decades, patients with diabetes mellitus continue to have significantly increased risk for vascular complications in comparison with individuals without diabetes mellitus [5]. An estimated 382 million people worldwide have diabetes mellitus and this number is expected to reach 592 million by the year 2035 [6]. Key manifestations of ASCVD in diabetes mellitus included advanced atherosclerosis manifest as coronary artery disease (CAD), ischemic stroke, peripheral vascular disease, and heart failure. Understanding the mechanisms, strategies for and challenges with managing ASCVD and heart failure risk in diabetes mellitus, as well as the potential cardiovascular risks and benefits of glucose-lowering drugs, is important for managing cardiovascular disease in diabetes mellitus [1]. Coronary computed tomography angiography (CCTA) has emerged as a non-invasive imaging modality for the detection or exclusion of CAD, with prior studies observing a high prevalence of CAD in asymptomatic type 2 diabetic patients using CCTA that is associated with worsened outcomes [7]. A

Computed tomography versus invasive coronary angiography: design and methods of the pragmatic randomised multicentre DISCHARGE trial.

More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266). In this trial, patients with a low-to-intermediate pretest probability (10-60%) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines. Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences. The DISCHARGE trial will assess the comparative effectiveness of CT and ICA. • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD.

Comprehensive Cardiac Magnetic Resonance Imaging in Patients With Suspected Myocarditis: The MyoRacer-Trial

BackgroundData suggest that T1 and T2 mapping have excellent diagnostic accuracy in patients with suspected myocarditis. However, the true diagnostic performance of comprehensive cardiac magnetic resonance (CMR) mapping versus endomyocardial biopsy (EMB) has not been determined. ObjectivesThis study assessed the performance of CMR imaging, including T1 and T2 mapping, compared with EMB in an unselected, consecutive patient cohort with suspected myocarditis. It also examined the potential role of CMR field strength by comparing 1.5-T versus 3.0-T imaging. MethodsPatients underwent biventricular EMB, cardiac catheterization (for exclusion of coronary artery disease), and CMR imaging on 1.5- and 3-T scanners. The CMR protocol included current standard Lake Louise criteria (LLC) for myocarditis as well as native T1, calculation of extracellular volume fraction (ECV), and T2 mapping (only on 1.5-T). Patients were divided into 2 groups according to symptom duration (acute: ≤14 days vs. chronic: >14 days). ResultsA total of 129 patients underwent 1.5-T imaging. In patients with acute symptoms, native T1 yielded the best diagnostic performance as defined by the area under the curve (AUC) of receiver-operating curves (0.82) followed by T2 (0.81), ECV (0.75), and LLC (0.56). In patients with chronic symptoms, only T2 mapping yielded an acceptable AUC (0.77). On 3.0-T, AUCs of native T1, ECV, and LLC were comparable to 1.5-T with no significant differences. ConclusionsIn patients with acute symptoms, mapping techniques provide a useful tool for confirming or rejecting the diagnosis of myocarditis and are superior to the LLC. However, only T2 mapping has acceptable diagnostic performance in patients with chronic symptoms. (Magnetic Resonance Imaging in Myocarditis [MyoRacer]; NCT02177630)

Chest pain: coronary CT in the ER.

Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years.

Clinical assessment of patients with chest pain; a systematic review of predictive tools.

BackgroundThe clinical assessment of patients with chest pain of recent onset remains difficult. This study presents a critical review of clinical predictive tools for the assessment of patients with chest pain.MethodsSystematic review of observational studies and estimation of probabilities of coronary artery disease (CAD) in patients with chest pain. Searches were conducted in PubMed, Embase, Scopus, and Web of Science to identify studies reporting tools, with at least three variables from clinical history, physical examination or ECG, produced with multivariate analysis, to estimate probabilities of CAD in patients with chest pain of recent onset, published from inception of the database to the 31st July 2015. The references of previous relevant reviews were hand searched. The methodological quality was assessed with standard criteria. Since the incidence of CAD has changed in the past few decades, the date of publication was acknowledged to be relevant in order to use the tool in clinical practice, and more recent papers were considered more relevant. Probabilities of CAD according to the studies of highest quality were estimated and the evidence provided was graded.ResultsTwelve papers were included out of the 19126 references initially identified. The methodological quality of all of them was high. The clinical characteristics of the chest pain, age, past medical history of cardiovascular disease, gender, and abnormalities in the ECG were the predictors of CAD most commonly reported across the studies. The most recent papers, with highest methodological quality, and most practical for use in clinical settings, reported prediction or exclusion of CAD with area under the curve 0.90 in Primary Care, 0.91 in Emergency department, and 0.79 in Cardiology. These papers provide evidence of high level (1B) and the recommendation to use their results in the management of patients with chest pain is strong (A).ConclusionsThe risk of CAD can be estimated on clinical grounds in patients with chest pain in different clinical settings with high accuracy. The estimation of probabilities of CAD presented in these studies could be used for a better management of patients with chest pain and also in the development of future predictive tools.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-016-0196-4) contains supplementary material, which is available to authorized users.