Invasive Coronary Angiography In Patients Research Articles

An exemplary reanalysis of coronary computed tomography angiography diagnostic meta-analyses shows insufficient data sharing and incorrect sensitivity and specificity estimates

ObjectivesTo systematically evaluate the reproducibility of primary data and, the reproducibility and correctness of pooled sensitivity and specificity estimates reported in a sample of diagnostic meta-analyses. Study Design and SettingWe conducted an exemplary systematic review of diagnostic meta-analyses comparing coronary computed tomography angiography to invasive coronary angiography in patients with suspected coronary artery disease. The objectives were to assess 1) the reproducibility of contingency tables, 2) the reproducibility of pooled sensitivity and specificity, and 3) differences to reported results when applying a recommended bivariate binomial model for pooling sensitivity and specificity. Therefore, we reproduced the contingency tables and recalculated sensitivity and specificity by utilizing both the pooling method of each meta-analysis and a bivariate binomial model. We used linear trends to assess the improvement of these objectives over time. ResultsWe identified 38 diagnostic meta-analyses, each including on average 19 primary studies (range: 3 to 89 studies; total: 715—including duplicates) with an average of approximately 1800 patients per meta-analysis (range: 118 to 7516 patients). For 31 meta-analyses (82%, 95% CI: 65%, 91%), the contingency tables were reproducible; however, only 15 published them. Using the pooling method of each meta-analysis, we obtained comparable recalculated sensitivities/specificities for 28 meta-analyses (74% [57%, 86%]). Only 11 meta-analyses pooled sensitivity/specificity using a bivariate binomial model (29% [16%, 46%]). When all meta-analyses were pooled with this model, published sensitivities/specificities were confirmed for 19 of 38 meta-analyses (50% [34%, 66%]). There was only marginal improvement in data availability and application of recommended pooling methods over time. ConclusionData sharing should become standard practice along with the use of appropriate pooling methods. Journal publication requirements may play a key role in enhancing the quality of scientific reporting and methodological standards which may lead to more reliable and consistent outcomes.The ability to reproduce sensitivity and specificity estimates in diagnostic imaging meta-analyses is dependent on the availability of contingency tables and the explicit reporting of pooling methods and software used.

Computed tomography angiography or invasive coronary angiography in patients with lowto intermediate risk acute coronary syndrome — a single-center study

Aim. To evaluate the strategy of using coronary computed tomography angiography (CCTA) in patients with low-to-intermediate risk of non-ST segment elevation acute coronary syndrome (NSTE-ACS) in relation to early (in-hospital) and long-term prognosis in comparison with standard management tactics.Material and methods. The study included 259 patients (men (M), 47,9%, mean age, 62,2±9,4 years). Patients in group 1 (n=148 people, M 46,6%, mean age 61,99±9,92 years) underwent CCTA to assess coronary involvement, and patients in group 2 (n=111 people, M 49,5%, mean age 62,4±8,6 years) — invasive coronary angiography (ICA). The follow-up lasted 18 months.Results. Patients in both groups were comparable in age, concomitant chronic diseases and smoking. Patients in the CCTA group compared with the ICA group had lower GRACE score and lower values of high-sensitivity Troponin I. In 85 patients (57,4%) of group 1 there was no coronary involvement, while 41 patients (27,7%) had <50% stenosis, 22 patients (14,9%) — >50% stenosis in at least one coronary artery. In group 2, the majority of patients also had non-involved coronary vessels (n=76; 68,5%), while hemodynamically insignificant (20-40%) and significant lesions were detected in 20 patients (12,3%) and 15 people (13,5%), respectively. In group 1, 20 patients were referred for ICA as follows: 10 patients underwent percutaneous coronary interventions; 2 patients had multivessel disease; in 4 patients, intraoperative fractional flow reserve revealed hemodynamically insignificant stenoses; in 4 remaining patients, no significant lesions were detected. All-cause mortality was 4,05% in the CCTA group, and 7,2% in the ICA group (p=0,28). In the CCTA group, cardiovascular mortality was 0%, and in the ICA group — 0,9% (p=0,43).Conclusion. CCTA in patients with low-to-intermediate risk ACS is not inferior to the standard tactics for managing these patients and significantly reduces the need for iCAG.

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain

The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown. To determine the association of age with outcomes of CT and ICA in patients with stable chest pain. The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023. Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy. MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years. Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients. Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients. ClinicalTrials.gov Identifier: NCT02400229.

Enhancing pre-transplant cardiac assessment: Validation and utility of the CAD-LT score with CCTA in liver transplant candidates

BackgroundCoronary computed tomography angiography (CCTA) is increasingly being used in the preoperative workup for liver transplantation (LT). We sought to assess the utility of integrating CCTA with the novel CAD-LT (Coronary Artery Disease in Liver Transplantation) score and its impact on reducing the need for invasive coronary angiography prior to LT. MethodsWe conducted a retrospective cohort study of consecutive patients (age ≥ 18 years) who underwent CCTA for LT workup between 2011 and 2018 at the Victorian Liver Transplant Unit, Melbourne, Australia. CAD-LT scores, a traditional risk factor-based criteria, were calculated, and patients stratified as low-, intermediate- or high-risk. ResultsOverall, 229 patients underwent CCTA. The mean age was 66 ± 5 years (82% male) with a modest-to-high risk factor burden (diabetes, 53%; hypertension, 46%; current or former smoker, 62%). The mean CAD-LT score of our cohort was 12.4 ± 4.0. No patients were classified as low-risk, 49 patients (21.4%) were deemed intermediate-risk and 180 patients (78.6%) were deemed high-risk. A high CAD-LT score (≥ 9) showed high sensitivity (95.3% [95% CI 86–98%]) and modest specificity (27.8% [95% CI 21–35%]) for the detection of obstructive coronary artery disease on CCTA, with a negative predictive value of 94%. Following multidisciplinary discussions, only 41 patients (18%) of patients proceeded to ICA of which 27% received percutaneous coronary intervention. ConclusionsThe use of CCTA in patients deemed intermediate- to high-risk by the CAD-LT score has the potential to reduce the need for invasive coronary angiography in patients undergoing LT workup.

Assessment of Coronary Stenosis Using Coronary CT Angiography in Patients with High Calcium Scores: Current Limitations and Future Perspectives

Coronary CT angiography (CCTA) is recognized for its role as a gatekeeper for invasive coronary angiography in patients suspected of coronary artery disease because it can detect significant coronary stenosis with high accuracy. However, heavy plaque in the coronary artery makes it difficult to visualize the lumen, which can lead to errors in the interpretation of the CCTA results. This is primarily due to the limited spatial resolution of CT scanners, resulting in blooming artifacts caused by calcium. However, coronary stenosis with high calcium scores often requires evaluation using CCTA. Technological methods to overcome these limitations include the introduction of high-resolution CT scanners, the development of reconstruction techniques, and the subtraction technique. Methods to improve reading ability, such as the setting of appropriate window width and height, and evaluation of the position of calcified plaque and residual visibility of the lumen in cross-sectional images, are also recommended.

Time to coronary catheterization in patients with non-ST-segment elevation acute coronary syndrome and high Global Registry of Acute Coronary Events score.

Current guidelines recommend an early (<24 h) invasive coronary angiography (ICA) strategy in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with Global Registry of Acute Coronary Events (GRACE) score over 140. Evidence for this recommendation is based on older trials. Between 1 February 2016 and 31 July 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA underwent ICA during index hospitalization. Six hundred and fifty-five patients underwent early invasive ICA (within 24 h) and 1112 underwent late ICA (between 24 h and 1 week). One hundred and seven patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent myocardial infarction (MI). Median time from admission to ICA was 13.3 h (IQR 6.0-20.6) for the early group and 59.9 h for the late group (IQR 23.5-96.3). There was no difference between the early and late ICA groups in the primary composite outcome [late catheterization >24 h hazard ratio 1.196, 95% confidence interval (CI) 0.969-1.475, P -value 0.096]. A multivariable Cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late catheterization >24 h hazard ratio 1.0735, 95% CI 0.862-1.327, P -value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (hazard ratio 1.291, 95% CI 0.910-1.831, P -value 0.151). An early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.

Time to coronary catheterization in patients with NST-ACS and high GRACE score

Abstract Introduction Current European guidelines recommend early (&amp;lt;24 hours) invasive coronary angiography (ICA) strategy in certain high-risk non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, including those with GRACE score over 140. The evidence for this recommendation is based on older trials using pre high-sensitive troponin (HsTn) biomarkers and non-contemporary therapy. Purpose To assess the association between GRACE score over 140, timing of ICA and their interaction on clinical outcomes in patients with ACS with no ST elevation, using (HsTn) as part of the calculated GRACE risk score. Methods and results Between February 1st 2016 and July 31th 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA, underwent ICA during index hospitalization. 655 (37%) patients underwent early-invasive ICA (within 24 hours) and 1112 (63%) underwent late ICA (between 24 hours and 1 week). 107 patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent MI. The median time from admission to ICA was 13.3 hours (IQR 6.0,20.6) for the early group and 59.9 hours for the late group (IQR 23.5,96.3). The vast majority of patients had re-vascularization (75.1%) performed, mostly by PCI (69.4%). There was no difference between the early and late ICA groups in the primary composite outcome (late Catheterization &amp;gt;24h HR 1.196, 95% CI 0.969-1.475, P-value 0.096). Using a multivariable cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late Catheterization &amp;gt;24h HR 1.0735, 95% CI 0.862-1.327, P-value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (HR 1.291 95% CI 0.910-1.831, p-0.151). Conclusion Early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.

Ventricular arrhythmia without acute coronary syndrome as an indication for invasive coronary angiography

Abstract Background In the clinical setting of acute coronary syndrome, ventricular arrhythmia is a validated indication for urgent invasive coronary angiography (ICA). However, the indication for ICA in patients with ventricular arrhythmia but no acute coronary syndrome is less clear. This study aimed to determine the incidence of occlusive coronary artery disease (CAD) in such patients and to evaluate the association of arrhythmia subtypes and ICA findings with survival. Methods This study included 309 patients who underwent ICA due to documented ventricular arrhythmia but no acute coronary syndrome between January 2004 and October 2017. Subtypes of arrhythmia and findings from ICA were correlated to outcome. Results Overall, 309 patients [240 male (78%) 69 female (22%), mean age 68 ± 11 y] with the evidence of ventricular arrhythmia were included. The documented ventricular arrhythmia were sustained ventricular tachycardia [VT; N= 140 (45.3%)], non-sustained ventricular tachycardia [nsVT; N= 97 (31.4%)], ventricular extrasystoles [VES; N= 72 (23.3%)]. A history of CAD was documented in 164 (53%) patients. The ICA detected a new CAD [N= 38 (12%)] or significant progression of known CAD [N= 72 (23%)] in 110 (36%) patients. Out of these patients 91 (83%) were treated with percutaneous coronary intervention (PCI), four (4%) were treated with coronary artery bypass grafting (CABG). The other 199 (64%) patients showed no progression of a known CAD [N= 92 (30%)] or no CAD [N= 107 (34%)] without significant progression. During a median follow-up time of 42 months (IQR 18-60), 44 (14.2%) patients died. The subtype of ventricular arrhythmia was associated to prognosis (figure 1). In all subgroups (VT, nsVT, VES), the survival analysis revealed no difference between patients with new CAD or progression of CAD on the one hand and those without CAD or progression on the other (VT: p = 0.70; nsVT: p = 0.65; VES: p = 0.14). Furthermore in all subgroups (VT, nsVT, VES), the survival analysis found no difference between patients with a specific treatment of CAD (PCI or CABG) and those without (VT: p = 0.37; nsVT: p = 0.95; VES: p = 0.07). Conclusion CAD is diagnosed in a relevant proportion of patients with ventricular arrhythmia but no evidence of an acute coronary syndrome. However, neither the successful detection of a new CAD or the progression of a known CAD nor the specific treatment (PCI or CABG) of a detected significant CAD had an impact on survival outcome. This challenges ventricular arrhythmia as an indication for ICA.Figure 1:Survival Curves

Computed Tomography Cardiac Angiography Before Invasive Coronary Angiography in Patients With Previous Bypass Surgery: The BYPASS-CTCA Trial.

Patients with previous coronary artery bypass grafting often require invasive coronary angiography (ICA). However, for these patients, the procedure is technically more challenging and has a higher risk of complications. Observational studies suggest that computed tomography cardiac angiography (CTCA) may facilitate ICA in this group, but this has not been tested in a randomized controlled trial. This study was a single-center, open-label randomized controlled trial assessing the benefit of adjunctive CTCA in patients with previous coronary artery bypass grafting referred for ICA. Patients were randomized 1:1 to undergo CTCA before ICA or ICA alone. The co-primary end points were procedural duration of the ICA (defined as the interval between local anesthesia administration for obtaining vascular access and removal of the last catheter), patient satisfaction after ICA using a validated questionnaire, and the incidence of contrast-induced nephropathy. Linear regression was used for procedural duration and patient satisfaction score; contrast-induced nephropathy was analyzed using logistic regression. We applied the Bonferroni correction, with P<0.017 considered significant and 98.33% CIs presented. Secondary end points included incidence of procedural complications and 1-year major adverse cardiac events. Over 3 years, 688 patients were randomized with a median follow-up of 1.0 years. The mean age was 69.8±10.4 years, 108 (15.7%) were women, 402 (58.4%) were White, and there was a high burden of comorbidity (85.3% hypertension and 53.8% diabetes). The median time from coronary artery bypass grafting to angiography was 12.0 years, and there were a median of 3 (interquartile range, 2 to 3) grafts per participant. Procedure duration of the ICA was significantly shorter in the CTCA+ICA group (CTCA+ICA, 18.6±9.5 minutes versus ICA alone, 39.5±16.9 minutes [98.33% CI, -23.5 to -18.4]; P<0.001), alongside improved mean ICA satisfaction scores (1=very good to 5=very poor; -1.1 difference [98.33% CI, -1.2 to -0.9]; P<0.001), and reduced incidence of contrast-induced nephropathy (3.4% versus 27.9%; odds ratio, 0.09 [98.33% CI, 0.04-0.2]; P<0.001). Procedural complications (2.3% versus 10.8%; odds ratio, 0.2 [95% CI, 0.1-0.4]; P<0.001) and 1-year major adverse cardiac events (16.0% versus 29.4%; hazard ratio, 0.4 [95% CI, 0.3-0.6]; P<0.001) were also lower in the CTCA+ICA group. For patients with previous coronary artery bypass grafting, CTCA before ICA leads to reductions in procedure time and contrast-induced nephropathy, with improved patient satisfaction. CTCA before ICA should be considered in this group of patients. URL: https://www. gov; Unique identifier: NCT03736018.

Utilisation of a Novel Risk Score to Reduce Invasive Coronary Angiography in Patients Undergoing Work-Up for Liver Transplantation

Utilisation of a Novel Risk Score to Reduce Invasive Coronary Angiography in Patients Undergoing Work-Up for Liver Transplantation

Real world impact of added FFR-CT to coronary CT angiography on clinical decision-making and patient prognosis – IMPACT FFR study

ObjectivesThe addition of CT-derived fractional flow reserve (FFR-CT) increases the diagnostic accuracy of coronary CT angiography (CCTA). We assessed the impact of FFR-CT in routine clinical practice on clinical decision-making and patient prognosis in patients suspected of stable coronary artery disease (CAD).MethodsThis retrospective, single-center study compared a cohort that received CCTA with FFR-CT to a historical cohort that received CCTA before FFR-CT was available. We assessed the clinical management decisions after FFR-CT and CCTA and the rate of major adverse cardiac events (MACEs) during the 1-year follow-up using chi-square tests for independence. Kaplan–Meier curves were used to visualize the occurrence of safety outcomes over time.ResultsA total of 360 patients at low to intermediate risk of CAD were included, 224 in the CCTA only group, and 136 in the FFR-CT group. During follow-up, 13 MACE occurred in 12 patients, 9 (4.0%) in the CCTA group, and three (2.2%) in the FFR-CT group. Clinical management decisions differed significantly between both groups. After CCTA, 60 patients (26.5%) received optimal medical therapy (OMT) only, 115 (51.3%) invasive coronary angiography (ICA), and 49 (21.9%) single positron emission CT (SPECT). After FFR-CT, 106 patients (77.9%) received OMT only, 27 (19.9%) ICA, and three (2.2%) SPECT (p < 0.001 for all three options). The revascularization rate after ICA was similar between groups (p = 0.15). However, patients in the CCTA group more often underwent revascularization (p = 0.007).ConclusionAddition of FFR-CT to CCTA led to a reduction in (invasive) diagnostic testing and less revascularizations without observed difference in outcomes after 1 year.Key Points• Previous studies have shown that computed tomography–derived fractional flow reserve improves the accuracy of coronary computed tomography angiography without changes in acquisition protocols.• This study shows that use of computed tomography-derived fractional flow reserve as gatekeeper to invasive coronary angiography in patients suspected of stable coronary artery disease leads to less invasive testing and revascularization without observed difference in outcomes after 1 year.• This could lead to a significant reduction in costs, complications and (retrospectively unnecessary) usage of diagnostic testing capacity, and a significant increase in patient satisfaction.

Atherosclerosis Imaging Quantitative Computed Tomography (AI-QCT) to guide referral to invasive coronary angiography in the randomized controlled CONSERVE trial.

We compared diagnostic performance, costs, and association with major adverse cardiovascular events (MACE) of clinical coronary computed tomography angiography (CCTA) interpretation versus semiautomated approach that use artificial intelligence and machine learning for atherosclerosis imaging-quantitative computed tomography (AI-QCT) for patients being referred for nonemergent invasive coronary angiography (ICA). CCTA data from individuals enrolled into the randomized controlled Computed Tomographic Angiography for Selective Cardiac Catheterization trial for an AmericanCollegeofCardiology(ACC)/AmericanHeartAssociation(AHA) guideline indication for ICA were analyzed. Site interpretation of CCTAs were compared to those analyzed by a cloud-based software (Cleerly, Inc.) that performs AI-QCT for stenosis determination, coronary vascular measurements and quantification and characterization of atherosclerotic plaque. CCTA interpretation and AI-QCT guided findings were related to MACE at 1-year follow-up. Seven hundred forty-sevenstable patients (60 ± 12.2 years, 49% women) were included. Using AI-QCT, 9% of patients had no CAD compared with 34% for clinical CCTA interpretation. Application of AI-QCT to identify obstructive coronary stenosis at the ≥50% and ≥70% threshold would have reduced ICA by 87% and 95%, respectively. Clinical outcomes for patients without AI-QCT-identified obstructive stenosis was excellent; for 78% of patients with maximum stenosis < 50%, no cardiovascular death or acute myocardial infarction occurred. When applying an AI-QCT referral management approach to avoid ICA in patients with <50% or <70% stenosis, overall costs were reduced by 26% and 34%, respectively. In stable patients referred for ACC/AHA guideline-indicated nonemergent ICA, application of artificial intelligence and machine learning for AI-QCT can significantly reduce ICA rates and costs with no change in 1-year MACE.

Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes

BackgroundThe ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid...

Abstract 12628: Evaluation of Time From Pre-Hospital Symptom Onset to Angiography on Coronary Artery Occlusion Status and Outcomes in Patients Presenting With NSTE-ACS

Introduction: Current guidelines for invasive coronary angiography (ICA) in patients presenting with NSTE-ACS outline two treatment pathways: early (within 24 hours [hrs]); or late (&gt;24 hrs). Time of hospital admission is used as the start time, however, we hypothesize that pre-hospital time of symptom onset may be a more optimal starting time. This study was designed to test optimal symptom onset-to-angiography time (OAT) and its association with the presence of coronary occlusion and adverse outcomes. Methods: Secondary data analysis in NSTE-ACS patients (pre-COVID-19) who underwent ICA. We tested the optimal cutoff point of OAT in classifying coronary occlusion using Youden-index analysis. We tested the association of OAT and in-hospital complication (i.e., myocardial infarction [MI] after admission, unplanned transfer to the cardiac intensive care unit, pulmonary edema, cardiogenic shock, dysrhythmia with intervention) and hospital length of stay [LOS]) using regression models. Results: In 163 patients: 124 (76%) had an occluded artery; 37 (23%) had an in-hospital complication. Overall, the mean OAT was 26±22 hrs (24±22 vs. 31±21, with and without occluded artery, respectively), and the median LOS was 55 hrs. The Youden-index optimum OAT cutoff point was 13.4 hrs. In the two logistic models, the adjusted OAT was associated with the presence of coronary occlusion (Figure A). OAT, as a continuous variable, was associated with LOS ( β =0.64, 95% CI 0.08-1.21, p =0.025), no other in-hospital complications were significant (Figure B). Conclusions: In patients presenting with NSTE-ACS, OAT at both 13.4 and &lt;24 hrs is a significant predictor of the presence of coronary artery occlusion. Every hour of delayed OAT was associated with a prolonged hospital LOS 0.64 hrs (38 min). Symptom onset appears to be an important starting point in determining optimal timing of ICA in patients with NSTE-ACS, but requires further study with a large sample of patients.

Invasive Coronary Angiography in Patients with Native or Prosthetic Aortic Valve Endocarditis.

Invasive coronary angiography (ICA) is essential to detect significant coronary artery disease (CAD) but is generally not recommended in patients with infective aortic valve endocarditis. This study aimed to evaluate the risks and benefits of preoperative ICA in patients before aortic valve replacement. Between March 2008 and September 2020, 232 patients were surgically treated for infectious endocarditis of the aortic valve. Sixty-seven (29%) of them underwent preoperative diagnostic ICA and were compared with the patients without preoperative ICA. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the ICA data. The intraoperative data and clinical outcomes after ICA and after surgery were evaluated. ICA revealed a CAD in the majority of our patients (n = 36; 54%): One-vessel disease n = 19 (28%), two-vessel disease n = 6 (9%), and three-vessel disease n = 11 (16%). We observed no adverse events following preoperative diagnostic ICA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischemia were detected. During surgical aortic valve replacement, concomitant coronary artery bypass grafting was performed in 20 patients (30%). In patients with preoperative ICA, postoperative in-hospital mortality was significantly lower (n = 8 [12%] vs. n = 30 [18%]; p < 0.001), while the incidence of postoperative bleeding was higher (n = 18 [27%] vs. n = 22 [13%]; p = 0.022). The new-onset stroke incidence was 5% in each group. Taking a multidisciplinary team approach, ICA is safe in selected patients with aortic valve infectious endocarditis with no adverse clinical outcomes, but significant clinical implications.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Percutaneous Coronary Intervention Pre-TAVR: Current State of the Evidence.

This review intends to give an up-to-date overview of the current state of evidence in the treatment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR), focusing on percutaneous coronary interventions (PCI) pre-TAVR. The recently published ACTIVATION trial is the 1st randomized trial comparing coronary revascularization (PCI) versus medical treatment in patients with significant CAD undergoing TAVR. With the caveat of several major limitations of the trial, the results of this study raised the question about the appropriateness of the common practice to routinely revascularize coronary stenosis before TAVR. Aortic valve stenosis is the most common valvular heart disease among the elderly and it often co-occurs with CAD. TAVR is increasingly considered an alternative to surgical aortic valve replacement not only in the elderly population but also in younger and lower-risk patients. The impact of co-existing CAD on clinical outcomes as well as the optimal timing of PCI in TAVR candidates is still unclear and the subject of ongoing randomized trials. Meanwhile, it is common practice in many centers to routinely perform invasive coronary angiography and PCI for significant coronary disease as part of the TAVR workup. While computed tomography angiography has emerged as a possible alternative to the invasive coronary angiography in patients with low pre-test probability for CAD, the value of functional invasive assessment of coronary lesions in the pre-TAVR setting has still to be clarified. Also, there is an increasing interest in the clinical relevance and optimal management of the potentially challenging coronary access post-TAVR, requiring further research.

Finding the Road to Rome in Cardiac Allograft Vasculopathy Imaging Surveillance.

Finding the Road to Rome in Cardiac Allograft Vasculopathy Imaging Surveillance.

Sex Effect in the Decision to Perform Invasive Coronary Angiography in Patients With Chronic Coronary Syndrome After Undergoing Vasodilator Stress MRI.

Stress cardiac MRI permits comprehensive evaluation of patients with known or suspected chronic coronary syndromes (CCS). The impact of sex on the use of invasive cardiac angiography (ICA) after vasodilator stress cardiac MRI is unclear. To evaluate the impact of sex on ICA use after vasodilator stress cardiac MRI. Retrospective. A total of 6229 consecutive patients (age [mean ± standard deviation] 65.2 ± 11.5 years, 38.1% women). A 5-T; a steady-state free-precession cine sequence; stress first-pass perfusion imaging; late enhancement imaging. Patients underwent vasodilator stress cardiac MRI for known or suspected CCS. The ischemic burden (at stress first-pass perfusion imaging) was computed (17-segment model). Multivariate logistic regression was used to evaluate the potential differential association between ischemic burden and use of cardiac MRI-related ICA across sex. A total of 1109 (17.8%) patients were referred to ICA, among which there were significantly more men (762, 19.7%) than women (347, 14.6%). Overall, after multivariate adjustment, female sex was not associated with lower use of ICA (odds ratio [OR]=0.99; confidence interval [CI] 95%: 0.84-1.18, P=0.934). However, significant sex differences were detected across ischemic burden. Whereas women with nonischemic vasodilator stress cardiac MRI (0 ischemic segments) were less commonly submitted to ICA (OR=0.49; CI 95%: 0.35-0.69) in patients with ischemia (>1 ischemic segment), adjusted use of ICA was more frequent in women than men (OR=1.27; CI 95%: 1.1-1.5). In patients with known or suspected CCS submitted to undergo vasodilator stress cardiac MRI, cardiac MRI-related ICA may be overused in men without ischemia. Furthermore, ICA referral in patients with negative ischemia resulted in greater odds of revascularization in men. 3 TECHNICAL EFFICACY: Stage 5.

Abstract 11910: Prevalence and Variation in Malnutrition in Non-Obstructive Coronary Artery Disease

Introduction: Prior work demonstrates up to 50% of patients with acute coronary syndrome are malnourished, as evaluated by the Controlling Nutritional Status (CONUT) score. We investigated the prevalence of malnutrition in stable nonobstructive coronary artery disease (CAD) detected by coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA). Methods: In a single-center, retrospective cohort, we examined the electronic health records of 429 patients with normal coronary arteries (NCA) without evidence of atherosclerosis on CCTA (n=144), nonobstructive CAD (&lt;70% stenosis) by CCTA (n=143), or ICA (n=142) on clinically ordered studies for chest pain or exertional dyspnea. CONUT scores, an aggregate of albumin, lymphocyte count, and total cholesterol, were calculated at time of CCTA or ICA in patients with available lab values. Patients within each group were stratified by severity of malnutrition defined as none (0-1), mild (2-4), moderate (5-7), or severe (8-12). Diabetic patients were excluded. Number of risk factors including history of hypertension, hyperlipidemia, or smoking were compared. Results: Among all patients with complete data (n=332), 33% overall had malnutrition, including 31% with mild, 2% with moderate, and none with severe malnutrition. In patients with NCA, 24% had malnutrition, compared to 31% in nonobstructive CAD by CCTA and 45% in ICA. There was a direct positive relationship between malnutrition presence and severity with age, cardiac risk factors and the presence of nonobstructive CAD ( Table ). Conclusions: Malnutrition is present in over one-third of stable patients with no obstructive CAD and directly associated with age, risk factor burden, and nonobstructive CAD. Future prospective studies are needed to understand whether malnutrition directly contributes to development of CAD or if age and cardiac risk factors associated with CAD lead to progression of malnutrition, or both.