Exclusion Of Coronary Artery Disease Research Articles

PR Interval and Sudden Cardiac Death in Patients With HIV Infection

To the Editor—We read with interest the article by Worm and colleagues, who reported no significant association between current or recent protease inhibitor exposure and sudden death or nonhemorrhagic stroke in the D:A:D study [1]. The investigators reported 78 sudden deaths over 234 818 patient-years of follow-up, a rate of 0.33 cases per 1000 patient-years (95% confidence interval [CI], .26–.41). First, we would like to clarify the issue of PR prolongation. Worm et al. write, “Prolongation of the PR interval could be an early manifestation of an ongoing conduction defect that may lead to complete AV block. Although rarely seen without other cardiac abnormalities, one possible clinical manifestation of severe PR interval prolongation may be congestive heart failure” [1p535]. Recent observational studies suggesting more heart failure hospitalizations or higher all-cause mortality were in individuals with known coronary artery disease and a PR interval of >220 msec [2] or >200 msec [3], respectively. Thus, PR prolongation of <200 msec alone, in the absence of Mobitz type II second degree block or a widened QRS interval, is of no prognostic significance for progression to advanced AV block [4], heart failure, or mortality. The PR interval is well-known to vary by the time of day the electrocardiogram is taken (a reflection of variation in vagal tone that influences AV nodal conduction), drugs taken (such as beta blockers), and heart rate. PR prolongation may also be a marker of heart failure because often such patients are prescribed beta blockers, which can prolong AV nodal conduction and thus the PR interval. Second, we found a mean sudden cardiac death rate of 2.6 cases per 1000 person-years (95% CI, 1.8–3.8) over a 10-year period in a single-center, retrospective cohort study of 2860 consecutive patients receiving care in a public human immunodeficiency virus (HIV) specialty clinic in San Francisco, California [5]. Cardiac deaths accounted for 13% of the overall mortality, and 86% of the cardiac deaths occurred suddenly. Although the sudden cardiac death rate was 4-fold lower than the rate of AIDS-related deaths (11.4 cases/1000 patient-years [95% CI, 9.6–13.6]), it was 4.5-fold higher than the contemporaneous citywide (98% HIV negative) adult sudden cardiac death rate in San Francisco [6], adjusted for age, sex, and ethnicity. The low sudden death rate reported by Worm and colleagues is in apparent conflict with our observed rate, which is much higher. However, this discrepancy is likely due to a major methodological difference, which is their use of a nonstandard definition of sudden death that specifically excluded causes due to coronary artery disease [7]. Coronary artery disease is in fact the largest overall contributor to sudden cardiac death, contributing to up to 80% of such deaths, according to many epidemiological studies [8]. Since coronary artery disease is a very important risk factor for sudden cardiac death, we specifically included these causes in our definition. Therefore, the sudden cardiac death rate reported in the D:A:D study may be some 5-fold lower than the actual rate, since only rare ion channelopathy (genetic) and cardiomyopathy causes of sudden cardiac death are captured after exclusion of coronary artery disease causes. In fact, multiplication of the sudden cardiac death rate reported in the D:A:D study (0.33 cases/1000 person-years) by 5 results in a rate more in range with the sudden cardiac death rate observed in our study (1.65 cases/1000 person-years vs 2.6 cases/1000 person-years). This discrepancy also highlights the difficulties with retrospective observational studies of deaths. For example, although we cross-checked multiple records, how many sudden cardiac deaths were not actually cardiac? What is the contribution of unmeasured factors such as drug use or occult overdoses? What is the role of antiretroviral drugs and coadminstered drugs, particularly in terms of QT interval prolongation? Thus, while prior studies may have underestimated sudden cardiac death rates, we may have overestimated it. Future prospective studies, including systematic autopsy evaluation, which is ongoing at our site, will be needed to provide additional insight into the actual causes of death, as well as the mechanisms underlying this disease process.

Stress Myocardial Perfusion Imaging in the Emergency Department - New Techniques for Speed and Diagnostic Accuracy

Emergency room evaluations of patients presenting with chest pain continue to rise, and these evaluations which often include cardiac imaging, are an increasing area of resource utilization in the current health system. Myocardial perfusion imaging from the emergency department remains a vital component of the diagnosis or exclusion of coronary artery disease as the etiology of chest pain. Recent advances in camera technology, and changes to the imaging protocols have allowed MPI to become a more efficient way of providing this diagnostic information. Compared with conventional SPECT, new high-efficiency CZT cameras provide a 3-5 fold increase in photon sensitivity, 1.65-fold improvement in energy resolution and a 1.7-2.5-fold increase in spatial resolution. With stress-only imaging, rest images are eliminated if stress images are normal, as they provide no additional prognostic or diagnostic value and cancelling the rest images would shorten the length of the test which is of particular importance to the ED population. The rapid but accurate triage of patients in an ED CPU is essential to their care, and stress-only imaging and new CZT cameras allow for shorter test time, lower radiation doses and lower costs while demonstrating good clinical outcomes. These changes to nuclear stress testing can allow for faster throughput of patients through the emergency department while providing a safe and efficient evaluation of chest pain.

Utilization of coronary computed tomography angiography for exclusion of coronary artery disease in ED patients with low- to intermediate-risk chest pain: a 1-year experience

ObjectiveWe describe our preliminary experience with coronary computed tomography angiography (CCTA) in emergency department (ED) patients with low- to intermediate-risk chest pain. MethodsA convenience cohort of patients with low- to intermediate-risk acute chest pain presenting to a suburban ED in 2009 were prospectively enrolled if the attending physician ordered a CCTA for possible coronary artery disease. Demographic and clinician data were entered into structured data collection sheets required before any imaging. The results of CCTA were classified as normal, nonobstructive (1%-50% stenosis), and obstructive (>50% stenosis). Outcomes included hospital admission and death within a 6-month follow-up period. ResultsIn 2009, 507 patients with ED chest pain had a CCTA while in the ED. The median (interquartile range) age was 54 (47-62) years; 51.5% were female. Thrombolysis in myocardial infarction risk scores were 0 (42.6%), 1 (42.2%), 2 (11.8%), 3 (2.4%), and 4 (1.0%). The results of CCTA were normal (n = 363), nonobstructive (n = 123), and obstructive (n = 21). Admission rates by CCTA results were obstructive (90.5%), nonobstructive (4.9%), and normal (3.0%). None of the patients with normal or nonobstructive CCTA died within the 6-month follow-up period (0%; 95% confidence interval, 0-0.9%). ConclusionsMany ED patients with low- to intermediate-risk chest pain have a normal or nonobstructive CCTA and may be safely discharged from the ED without any associated mortality within the following 6 months.

Arrhythmic Manifestations in Patients With Congenital Left Ventricular Aneurysms and Diverticula

Congenital left ventricular aneurysms and diverticula (LVA/Ds) are rare cardiac malformations that can be detected using echocardiography or other imaging techniques. Some of these patients present with ventricular arrhythmias. This study investigated clinical characteristics of patients with congenital LVA/D presenting with arrhythmic manifestations. Over the previous 20 years 250 patients were diagnosed to have congenital LVA/D at our institution. Diagnosis was made using echocardiography after exclusion of coronary artery disease, local cardiac inflammatory processes, traumatic causes, or cardiomyopathies. At initial presentation 32 of the 250 patients (13%, average age 45 years, range 25 to 65, 21 men and 11 women) exhibited arrhythmias. At least 2 LVA/Ds were present in 6 of these patients. LVA/Ds were localized at the posterobasal, apical, anteroseptal, and anterolateral walls in 12, 11, 4, and 5 patients, respectively. The most common complaints at presentation were syncope or presyncope in 18 patients and palpitations in 11 patients. One patient had survived sudden cardiac death. Long-term electrocardiographic recordings showed ventricular tachycardia (VT) or ventricular fibrillation in 17 patients (53%). Twelve patients underwent electrophysiologic testing. Nine patients had inducible ventricular tachyarrhythmia, whereas induced tachycardia was similar to that during spontaneous arrhythmia in 7 patients. In conclusion, patients with congenital LVA/Ds who present with arrhythmic manifestations commonly have VT. Electrophysiologic testing can reproduce clinical VT in most of these patients.

Indications, imaging technique, and reading of cardiac computed tomography: survey of clinical practice

To obtain an overview of the current clinical practice of cardiac computed tomography (CT). A 32-item questionnaire was mailed to a total of 750 providers of cardiac CT in 57 countries. A total of 169 questionnaires from 38 countries were available for analysis (23%). Most CT systems used (94%, 207/221) were of the latest generation (64-row or dual-source CT). The most common indications for cardiac CT was exclusion of coronary artery disease (97%, 164/169). Most centres used beta blockade (91%, 151/166) and sublingual nitroglycerine (80%, 134/168). A median slice thickness of 0.625 mm with a 0.5-mm increment and an 18-cm reconstruction field of view was used. Interpretation was most often done using source images in orthogonal planes (92%, 155/169). Ninety percent of sites routinely evaluate extracardiac structures on a large (70%) or cardiac field of view (20%). Radiology sites were significantly more interested in jointly performing cardiac CT together with cardiology than cardiologists. The mean examination time was 18.6 ± 8.4 min, and reading took on average 28.7 ± 17.8 min. Cardiac CT has rapidly become established in clinical practice, and there is emerging consensus regarding indications, conduct of the acquisition, and reading.

The feasibility of nurse-led assessment in acute chest pain admissions by means of coronary computed tomography

Cardiac computed tomography (CCT) is a non-invasive imaging technique for the diagnosis of coronary artery disease (CAD). The National Institute for Health and Clinical Excellence (NICE) recommend CCT for selected patients in the assessment of chest pain of recent onset. To assess the feasibility and utility of CCT in a nurse-led, protocol-based assessment of chest pain. Patients admitted over 4 months with suspected angina were assessed for eligibility for CCT by a specialist nurse. Eligibility was defined by: a likelihood of CAD < 90%, no features of acute coronary syndrome, no contra-indications to the scanning process, and the ability to give written consent. An age and sex-matched historical cohort (for whom CCT was unavailable) was compared with the CCT cohort with regard to the diagnosis or exclusion of CAD at 3 months post-discharge from hospital. Of 198 patients admitted, 98 were identified as eligible for CCT. Of these, 37 were recommended for alternative management on cardiologist review, 18 declined consent, 23 were unable to be scanned within 24 h prior to discharge and 14 underwent CCT. CAD was diagnosed or excluded in 14/14 patients undergoing CCT. CAD was diagnosed or excluded in 11/14 patients investigated without CCT, leaving 3/14 patients with no clear diagnosis. This study suggests nurses may be trained to assess patients for CCT within agreed protocols. In the UK it is likely these protocols will be based on NICE guidance. Despite potential diagnostic utility, CCT appears likely to form a small percentage of cardiac investigations undertaken.

Sleep apnoea in severe aortic stenosis

BackgroundThere are as yet no data on the prevalence of sleep apnoea in patients with severe aortic stenosis (AS).AimsTo assess the occurrence, severity and clinical correlates of sleep apnoea in...

Incidence of Sleep-Disordered Breathing in Patients With Hypertrophic Cardiomyopathy

The authors investigated the prevalence of sleep-disordered breathing (SDB) together with its clinical correlations in patients with hypertrophic cardiomyopathy (HCM). A total of 113 consecutive patients including 63 patients with HCM (40 men; mean age, 59.5±13.0 years; New York Heart Association class, 2.0±0.9) underwent cardiorespiratory polygraphy in addition to their clinical work-up including echocardiography. Patients with an apnea-hypopnea-index (AHI) ≥5/h were considered to have SDB. If thoracic and abdominal inspiration efforts were documented, SDB was considered to be obstructive sleep apnea (OSA), otherwise SDB was considered to be central sleep apnea (CSA). The age- and sex-matched control group of 50 patients had exclusion of coronary artery disease by angiography, and normal left ventricular (ejection fraction ≥55%) and valvular function. SDB was diagnosed in 52 patients (82.5% vs 72% in the control group; P =not significant) with a mean AHI of 23.0±17.8/h. Severity of SDB was higher in patients with HCM than in the control group (AHI 12.2±7.6/h; P =.003). OSA was documented in 39 patients (AHI 21.2±16.5/h) and CSA in 13 (AHI 28.4±20.9/h). The severity of SDB correlated with New York Heart Association functional class (η=0.9, η(2) =0.811) and with left ventricular end-diastolic (r=0.6, P <.01) and left atrial (r=0.4, P <.01) diameter. No correlations were found between SDB and other clinical or echocardiographic parameters. SDB is common in patients with hypertrophic cardiomyopathy, with a predominance of OSA and correlations with markers of left ventricular function.

Prolonged pain to hospital time is associated with increased plasma advanced oxidation protein products and poor prognosis in patients with percutaneous coronary intervention for ST-elevation myocardial infarction

Plasma advanced oxidation protein products (AOPP) are a biomarker for increased production of reactive oxygen species. We examined the possible association between pain to hospital time, plasma AOPP, and outcome of patients receiving percutaneous coronary intervention (PCI) for ST-elevation acute myocardial infarction (STEMI). Plasma AOPP was determined at hospitalization as well as 24 and 48 h after PCI in 79 patients with suspected STEMI. Patients were stratified into a control group (Group I, n = 21) after exclusion of coronary artery disease, Group II (n = 46) with pain to hospital time <12 h, and Group III (n = 33) with pain to hospital time >12 h. Associations between pain to hospital time and AOPP as well as incidence of major adverse cardiac events (MACE) during 6 months of follow-up were analyzed. Plasma AOPP at admission was significantly higher in patients of Group II (97.58 +/- 23.41 micromol/l) and Group III (184.52 +/- 30.41 micromol/l) in comparison with Group I (57.41 +/- 13.60 micromol/l, all P < 0.001). Plasma AOPP concentration was positively correlated with pain to hospital time and associated with an increased incidence of MACE during the 6-month follow-up period. Prolonged ischemia is associated with increased oxidative stress and poor prognosis in patients treated with PCI for STEMI.

Prevalence and Clinical Characteristics of Symptomatic Patients with Obstructive Coronary Artery Disease in the Absence of Coronary Calcifications

The quantification of coronary calcification has established itself as a valid risk marker to predict cardiovascular events. However, data derived from cardiac multi-detector row computed tomography could demonstrate that the exclusion of coronary calcification is not synonymous with the exclusion of coronary artery disease (CAD). The aims of this retrospective analysis were to determine the prevalence of significant CAD in a symptomatic cohort with indications for invasive angiography but without coronary calcification (Agatston score 0) as assessed by multislice computed tomography and to investigate whether there were any differences in terms of risk factors between patients with and without significant CAD. Five hundred multislice computed tomographic scans (in 371 men and 129 women) were included in the analysis. Agatston scores were determined on native scans. All patients underwent coronary angiography to detect or rule out obstructive CAD. Patients with negative calcium scoring were selected and divided into two subgroups: those without obstructive CAD and those with obstructive CAD (luminal stenoses > 50%). These subgroups were characterized in terms of clinical characteristics (age and sex) and cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipoproteinemia, familial predisposition, smoking, and overweight). Sixty-one of 500 patients (12.2%) had negative calcium scores (Agatston score 0). Sixteen of these patients (26.3%, or 3.2% of the total population) had obstructive CAD according to invasive angiography. Patients with obstructive CAD were significantly older (mean age, 64 ± 9 vs 55 ± 10 years; P = .003) and were more frequently diabetic (25% vs 4%, P = .0389) than patients without obstructive CAD. There were no significant differences with regard to the other risk factors. In this high-risk population, the absence of coronary calcification was not sufficient to rule out CAD. Among patients without coronary calcification, the presence of significant CAD was associated with increased age and the presence of diabetes mellitus.

Biomarkers of Vulnerable Plaque: The Missing Link With Ischemia

The initial evaluation of chest pain in the emergency department is based on the patient's clinical history, changes in the ECG and necrosis biomarkers. Although management of patients with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction with positive markers of myocardial damage is well defined, exclusion of coronary artery disease or myocardial ischemia in the remaining patients is more challenging. This group represents the majority of patients admitted for chest pain syndromes and that have a substantial risk of an adverse outcome. Given that troponin, as a marker of myocardial damage, detects terminal events in the cascade of acute coronary syndrome, there is a need to search for biomarkers that are able to identify patients at high risk, allowing rapid, bedside stratification. Data suggest that clinical events are prone to occur more frequently in patients with coronary artery stenosis associated with myocardial ischemia. Accordingly, identification of systemic biomarkers of ischemia could facilitate identification of high-risk patients with a high burden of coronary atherosclerosis and plaque rupture. We describe six biomarkers that have been linked to myocardial ischemia. Until now, these biomarkers of ischemia are relevant in order to exclude ischemic heart disease (high negative predictive value) but still lack specificity. Future prospective studies should be performed in larger and more diverse sets of patients presenting with ischemia, and in a complementary fashion in order to provide valuable tools for clinical decision making.

Clinical Usefulness of CT Coronary Angiography in the Exclusion of Coronary Artery Disease

Clinical Usefulness of CT Coronary Angiography in the Exclusion of Coronary Artery Disease

Evaluation of plaque instability

CT angiography is commonly used for exclusion of coronary artery disease and demonstration of the extent of coronary vascular involvement. It has been recently proposed that definition of vessel wall characteristics at the site of luminal stenosis may serve as a useful prognostic tool. Presence of positively remodeled plaques with low attenuation portends a greater risk for development of acute coronary events. Although not recommended currently as a population-based strategy, CT angiographic examination may help identify very high-risk asymptomatic subjects.

Survey regarding the Clinical Practice of Cardiac CT in Germany: Indications, Scanning Technique and Reporting

To obtain an overview of the current clinical practice of cardiac computed tomography (CT) in Germany. A 30-item questionnaire was mailed to 149 providers of cardiac CT in Germany. The items asked about indications, scanning technique and reporting, data storage, and cost of the examination. Overall 45 questionnaires could be analyzed (30 %). The majority of centers (76 %, 34 of 45 centers) used CT scanners of the latest generation (at least 64 rows). The most common appropriate indications were exclusion of coronary artery disease (91 %, 41 / 45), coronary anomalies (80 %, 36 / 45), and follow-up after coronary artery bypass grafting (53 %, 24 / 45). Each center examined on average 243 +/- 310 patients in 2007 and the number of centers performing cardiac CT increased significantly in 2007 (p = 0.035) compared with the preceding year. Most used sublingual nitroglycerin (84 %, 38 / 45; median of 2 sprays = 0.8 mg) and/or a beta blocker (86 %, 39 / 44; median of 5 mg IV, median heart rate threshold: 70 beats/min). Many providers used ECG-triggered tube current modulation (65 %, 29 / 44) and/or adjusted the tube current to the body mass index or body weight (63 %, 28 / 44). A median slice thickness of 0.75 mm with a 0.5 mm increment and a 20 cm field-of-view was most commonly used. Source images in orthogonal planes (96 %, 43 / 45), curved MPRs (93 %, 42 / 45), and thin-slice MIPs (69 %, 31 / 45) were used most frequently for interpretation. Extracardiac structures were also evaluated by 84 % of the centers (38 / 45). The mean examination time was 16.2 min and reporting took an average of 28.8 min. Cardiac CT has rapidly become an established procedure with standards regarding indications, scanning technique, and reporting.

Multislice Computed Tomography in the Exclusion of Coronary Artery Disease in Patients With Presurgical Valve Disease

Background— Multislice computed tomography (MSCT) has shown high negative predictive value in ruling out obstructive coronary artery disease. Preliminary studies in patients with valvular heart disease (VHD) have demonstrated the potential of MSCT angiography (CTA) in such patients, precluding need for invasive angiography (XA). However, larger prospectively designed studies, including patients with atrial fibrillation and incorporating dose reduction algorithms, are needed. Methods and Results— To evaluate the clinical utility of 64-slice CT in the preoperative assessment in patients with VHD, we prospectively studied 452 consecutive patients undergoing routine cardiac catheterization for eligibility. Two hundred thirty-seven patients underwent both MSCT and XA. Segment-based, vessel-based, and patient-based agreement between CTA and XA was estimated assuming that “nonevaluable” segments were positive for significant coronary stenosis. In a patient-based analysis, sensitivity, specificity, positive predictive value, and negative predictive values of CTA were 95%, 89%, 66%, and 99%, respectively; in vessel-based analysis, 90%, 92%, 48%, and 99%, respectively; and in segment-based analysis, 89%, 97%, 38%, and 100%, respectively. No significant differences were found between patients with or without atrial fibrillation. A CAC value of 390 was the best cutoff for the identification of patients with positive or inconclusive CTA (which would not be exempted from XA in the clinical setting). Conclusions— In the preoperative assessment of patients with predominant VHD, the diagnostic accuracy of 64-slice CTA for ruling out the presence of significant coronary artery disease is very good even when including patients with irregular heart rhythm. Using this approach, CAC quantification before CTA can be successfully used to identify patients who should be referred directly to XA, sparing unnecessary exposure to radiation.

Three-Year Outcomes and Cost Analysis in Patients Receiving 64-Slice Computed Tomographic Coronary Angiography for Chest Pain

Sixty-four slice computed tomographic coronary angiography (CTCA) is being used more often in the evaluation of patients with chest pain. The strength of this test is its high specificity and negative predictive value in exclusion of coronary artery disease (CAD). Its use remains controversial because there are theoretical risks of radiation, additional costs of the test, and no long-term data to suggest that excluding CAD by use of this test results in positive patient outcomes. A total of 436 patients underwent 64-slice CTCA because of chest pain thought to be anginal. Cardiac computed tomography was ordered by the primary physician or cardiologist based on a low to intermediate pretest probability of flow-limiting CAD. A smaller subset of patients initially underwent stress testing but had equivocal findings or continued symptoms that warranted further evaluation. Of the total patient cohort, 376 had "no significant CAD" based on computed tomographic coronary angiographic results. Of the 60 patients who were believed on computed tomographic coronary angiogram to have "flow-limiting" CAD, 34 (57%) ended up having percutaneous coronary intervention or coronary artery bypass grafting. The remaining 26 patients (43%) did not have true flow-limiting disease on coronary catheterization and were treated medically. With follow-up of 36 months, 376 of those patients (100%) with minimal or no disease by CTCA were free of events or intervention. In conclusion, in a real-world, clinical setting, the negative predictive value of low-risk CTCA is very high and exceptionally helpful in predicting freedom from events for up to 3 years. By avoiding further invasive treatments, there is a significant potential cost savings in patients who are sent for noninvasive coronary angiography rather than invasive angiography.

Increased levels of laminin and collagen type VI may reflect early remodelling in patients with acute myocardial infarction

Objective — The development of left ventricular remodelling (LVR) after acute myocardial infarction (AMI) is a predictor of heart failure and mortality.The extracellular matrix (ECM) is highly susceptible to ischaemic injury. Laminin and collagen type VI (CVI) contribute to ECM formation in the infarct zone.To determine whether these markers can be detected in blood samples, we measured laminin and CVI in patients with AMI and control subjects.Methods — A total of 60patients scheduled for coronary angiography and 31patients with AMI were included.We subdivided the patients into three groups: (1) AMI, (2) stable coronary artery disease (CAD) and (3) exclusion of CAD. Laminin and CVI serum concentrations were recorded using the ELISA-technique.Results — Laminin was significantly higher in patients with AMI than in subjects with stable CAD (36.5 vs. 23.9, P<0.01) or without CAD (36.5 vs. 24.6ng/ml, P<0.05). CVI-levels were significantly elevated in patients with AMI compared to subjects without CAD (7.5ng/ml vs. 5.4ng/ml, P<0.05) or stable CAD (7.5ng/ml vs. 5.7ng/ml, P=0.01). Laminin and CVI were significantly higher in patients with severely reduced left ventricular function. Laminin and CVI values were significantly correlated (r=0.6).Conclusion — Our data suggest that laminin and CVI serum levels can be potential surrogate parameters of ECM remodelling after AMI.We hypothesize that serum laminin reflects early ECMremodelling involved in the process of postischaemic tissue degradation and repair, and CVI may be a marker of collagen denaturation and shifts in the collagen phenotype ratios.

Multislice Computed Tomography in Infective Endocarditis: Comparison With Transesophageal Echocardiography and Intraoperative Findings

The aim of this study was to assess the value of multislice computed tomography (CT) for the assessment of valvular abnormalities in patients with infective endocarditis (IE) in comparison with transesophageal echocardiography (TEE) and intraoperative findings. Multislice CT has recently shown promising data regarding valvular imaging in a 4-dimensional fashion. Thirty-seven consecutive patients with clinically suspected IE were examined with TEE and 64-slice CT or dual-source CT. Twenty-nine patients had definite IE and underwent surgery. The diagnostic performance of CT for the detection of evident valvular abnormalities for IE compared with TEE was: sensitivity 97%, specificity 88%, positive predictive value (PPV) 97%, and negative predictive value (NPV) 88% on a per-patient basis (n = 37; excellent intermodality agreement kappa = 0.84). CT correctly identified 26 of 27 (96%) patients with valvular vegetations and 9 of 9 (100%) patients with abscesses/pseudoaneurysms compared with the intraoperative specimen. On a per-valve-based analysis, diagnostic accuracy for the detection of vegetations and abscesses/pseudoaneurysms compared with surgery was: sensitivity 96%, specificity 97%, PPV 96%, NPV 97%, and sensitivity 100%, specificity 100%, PPV 100%, NPV 100%, respectively, without significant differences as compared with TEE. Vegetation size measurements by CT correlated (r = 0.95; p <0.001) with TEE (mean 7.6 +/- 5.6 mm). The mobility of vegetations was accurately diagnosed in 21 of 22 (96%) patients with CT, but all of 4 leaflet perforations (<or=2 mm) were missed. CT provided more accurate anatomic information regarding perivalvular extent of abscess/pseudoaneurysms than TEE. Multislice CT shows good results in detecting valvular abnormalities in IE and could be applied in pre-operative planning and exclusion of coronary artery disease before surgery.

Morphology and beyond: CT of cardiac valves

Multi-detector row CT has developed into a valuable tool for noninvasive imaging of the heart. The major indication of cardiac CT represents the diagnosis or exclusion of coronary artery disease. Owing to its cross-sectional nature, the same data obtained for the coronary arteries contain morpho-anatomical information about the cardiac chambers and valves. When scanning in the retrospectively electrocardiography-gated mode, data can be reconstructed in various phases of the cardiac cycle. This enables assessing the movement of the open and closed valves. When performing planimetric measurements of the valve opening and regurgitant orifice areas in case of stenotic and regurgitant valves, estimations of valvular function can be given that correlate well with the results from echocardiography. This article reviews the current evidence regarding the accuracy of CT for imaging the morphology and function of the cardiac valves.

Abstract 1205: Patients without obstructive coronary artery disease and stress test results: An analysis from the National Cardiovascular Data Registry

Background: In stable patients without known coronary artery disease (CAD), clinical practice guidelines recommend documentation of ischemia prior to evaluation by invasive angiography. We sought to determine how often non-invasive stress testing is performed in this population and the association between stress test results and obstructive CAD. Methods: Patients undergoing cardiac catheterization for exclusion of CAD who were without prior history of myocardial infarction, PCI, or CABG were identified from 601 hospitals using the American College of Cardiology National Cardiovascular Data Registry between 2005 – 2007. Significant obstructive CAD was defined as the presence of any stenosis ≥ 50% left main or ≥ 70% major epicardial vessel. Patient demographics, risk factors, symptoms, stress test status and CAD presence were determined. Results: A total of 376,430 patients without known CAD were identified. The median age was 61 years, 53% were male, 26% had diabetes, and 69% had hypertension. At angiography, 142,912 (38%) of patients were found to have significant obstructive CAD. Symptom status was associated with the presence of CAD (stable angina 50%, atypical 25%, asymptomatic 40%; p&lt;0.001). Stress testing was performed in 316,248 (84%) of patients prior to angiography, and results were associated with the presence of CAD (p&lt;0.001) see Table . Although a positive stress test was noted in 255,617 (68% of patients undergoing cath), obstructive CAD was noted in only 105,435, yielding a positive predictive value of 41%. Conclusions: In a large national registry of stable patients without known CAD undergoing invasive angiography, only 38% were found to have significant obstructive disease. Although performed in 84% of patients prior to cath, the low positive predictive value of current stress tests may have contributed to the high rate of patients without obstructive CAD. Table p value for stress test results and presence of obstructive CAD p&lt;0.001