Localization Of Coronary Artery Disease Research Articles

Difference in the topography of atherosclerosis in the left versus right coronary artery in patients referred for coronary angiography

BackgroundWe sought to determine the difference in the localization of coronary artery disease (CAD) between the left and right coronary artery system and investigate the effect of sex and age on that difference.MethodsWe retrospectively analyzed 17,323 consecutive angiographies from January 1st, 1984 to December 31st, 2003. The demographic parameters, in particular age and sex of the investigated cases as well as the angiographic results were recorded and summarized.ResultsOf 13,305 cases with CAD, 861 (6.5%) had right coronary artery (RCA)-only disease, 4,621 (34.7%) had left coronary artery (LCA)-only disease, while 7,823 (58.8%) cases had concomitant RCA and LCA disease. LCA-only disease was more frequent than RCA-only disease [LCA-only/RCA-only odds ratio (OR): 5.37, 95% CI: 4.99 to 5.77, p < 0.001]. Women were more likely to have LCA-only disease (men/women OR 0.75 95% CI: 0.68 to 0.82, p < 0.001) compared with men who were more likely to present with concomitant RCA and LCA disease (men/women OR 1.33 95% CI: 1.21 to 1.45, p < 0.001). RCA-only and LCA-only disease were both more frequent in patients aged from 51 to 60 years, while concomitant RCA and LCA disease in patients between 61 and 70 years of age.ConclusionsLCA-only disease is more frequent than RCA-only disease. Men have a higher probability than women to present with concomitant RCA and LCA disease while women are more likely than men to be found with LCA-only disease.

Abstract 3137: Failure of the Chromosome 9p21 Locus to Predict Myocardial Infarction when Non-Event Patients’ Coronary Disease Phenotype is Angiographically-Characterized

A chromosome 9p21 locus is associated with coronary heart disease (CHD) phenotypes in at least 25 independent populations, but multiple clinically-distinct phenotypes have been evaluated. Utilizing angiographic coronary artery disease (CAD) phenotyping, this study evaluated whether 9p21 single nucleotide polymorphisms (SNPs) predict ischemic events (e.g., myocardial infarction [MI]) among CAD patients. Two populations of patients undergoing coronary angiography during 1994 –2007 (population 1: N=1,748; population 2: N=1,014) were evaluated for association of a 9p21 tagging SNP (rs2383206, A–&gt;G) with a composite MI/death endpoint vs. no event among patients with angiographically-significant CAD. Secondary analyses evaluated rs2383206 in two additional angiographic populations that included both CAD and non-CAD patients (population 3: N=2,122; population 4: N=1,466) for the phenotypes of MI vs. CAD/no MI, MI vs. no CAD, and CAD/no MI vs. no CAD. Post hoc analysis evaluated three other 9p21 SNPs. No association of rs2383206 was found with MI/death in populations 1 (OR=0.95 per G allele, p-trend=0.48) and 2 (OR=0.91 per G allele, p-trend=0.28), or with MI vs. CAD/no MI in populations 3 (OR=0.96 per G allele, p-trend=0.57) and 4 (OR=0.89 per G allele, p-trend=0.21). Among CAD patients, no association of rs2383206 was found with Duke CAD Index, number of significantly diseased vessels, left main disease, ostial disease, or proximal disease in the four populations. In contrast, rs2383206 was associated with CAD/no MI compared with no CAD (population 3: p-trend=0.0001; population 4: p-trend=0.0008). These findings were confirmed for rs2383207, rs10757274, and rs10757278. The chromosome 9p21 locus was not associated with MI or a composite of MI/death, or with extent or location of CAD, although it did predict CAD presence. This suggests that 9p21 is involved in the initiation or facilitation of CAD, not CAD progression or the precipitation of acute events. These findings contradict prior reports of a 9p21 association with MI, likely due to differences in study design and phenotype quality. High-quality angiographic phenotyping would be a useful standard in genetic association studies of CHD.

Late drug-eluting stent thrombosis in unprotected left main coronary artery lesions--sometimes possible, but rarely definite or probable

Beyond relieving angina, revascularization strategies for coronary artery disease (CAD) have focused on the subsequent occurrence of death, myocardial infarction, repeat revascularization, and, more recently, stent thrombosis. Numerous trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have shown the long-term rates of death and myocardial infarction to be similar between these strategies, largely independently of the extent and location of CAD.1,2 The main outcome gap between percutaneous and surgical approaches has been the higher rate of repeat revascularization procedures for those initially undergoing PCI. At 5-year follow-up in the Bypass Angioplasty Revascularization Investigation (BARI) trial,1 54% of patients initially undergoing multivessel balloon angioplasty required a repeat procedure vs. 8% among those assigned to bypass surgery. With the introduction of bare-metal stents (BMS), this gap between PCI and CABG was narrowed. The 5-year follow-up from the Arterial Revascularization Therapies Study (ARTS) trial2 demonstrated the need for repeat target vessel revascularization (TVR) for those undergoing multivessel stent placements vs. CABG to be 30 and 9%, respectively. Most recently, drug-eluting stents (DES) have reshaped the landscape of interventional cardiology by substantially reducing rates of restenosis, and this intuitively should narrow the repeat TVR gap between PCI and bypass surgery further. In particular, the 5-year data from randomized trials comparing BMS and DES3,4 have shown TVR rates to be additionally reduced by one-half to two-thirds with DES, such that the ∼10–15% need for repeat revascularization for the DES cohort at long-term follow-up should be nearing that associated with bypass surgery. Several important CAD subsets, such as chronic total occlusions, complex bifurcation lesions, and stenoses of unprotected left main coronary arteries (ULMCAD), have been considered unattractive or ‘verboten’ for PCI, but are being increasingly considered with the availability of DES. Large-scale trials comparing … *Corresponding author. Tel: +1 859 323 5843, Fax: +1 859 257 3537, Email: Moliterno{at}uky.edu

Direct comparison between pharmacological stress with adenosine triphosphate disodium and exercise stress myocardial perfusion imagings

To clarify the significance of adenosine triphosphate disodium stress myocardial perfusion imaging (ATP-MPI), we directly compared the findings of ATP-MPI with those of exercise stress myocardial perfusion imaging (Ex-MPI). ATP-MPI, Ex-MPI, and coronary angiography (CAG) were performed within 60 days in 17 coronary artery disease patients with mean age of 62.1+/-7.9 years. CAG revealed single-vessel disease (SVD) in 10 patients and multivessel disease (MVD) in seven patients. The summed stress score (SSS) of ATP-MPI was significantly higher than that of Ex-MPI (10.0 [7.8-14.3] vs. 8.0 [4-18], P<0.05). No difference in the SSS was observed between ATP-MPI and Ex-MPI in patients with SVD (8.0 [6.0-9.0] vs. 8.0 [6.0-10.0], NS), whereas this difference was significant in patients with MVD (15.0 [14.0-22.8] vs.9 [7.3-16.3], P<0.05). There was no difference in the summed rest score between ATP-MPI and Ex-MPI. The univariate logistic analysis showed that "MVD" was the significant factor influencing to the overt discrepancy between ATP-MPI and Ex-MPI (odds ratio: 9.0, 95% confidence interval: 1.07-75.84, P=0.043). The accuracy of ATP-MPI and Ex-MPI in detecting the territory of stenotic coronary vessel or previous myocardial infarction was 98.0% and 92.1% (NS), respectively. In conclusion, ATP-MPI is useful for detecting potential ischemic areas that cannot be detected by Ex-MPI, particularly in patients with MVD.

Traditional Risk Factors Are Predictive on Segmental Localization of Coronary Artery Disease

The aim of this study was to investigate the relationship between established risk factors and segmental localization of coronary artery disease. A total of 2760 patients who underwent coronary angiography were enrolled into the study. Coronary angiographic segmental evaluation was performed according to the scheme of American Heart Association. Patients were classified into 2 groups (group 1: normal coronary artery segments, group 2: coronary artery segments with coronary artery disease). Smoking was highly related with left main coronary artery disease (odds ratio = 7.5; P = .005). Diabetes mellitus and male sex increased the risk of atherosclerosis in all coronary vasculature (odds ratio = 2.7-2.2; P < .001-P < .001). Hypertension was correlated with distal coronary artery (odds ratio = 1.4; P < .001) and family history with distal circumflex lesions (odds ratio = 4.5; P = .005) High triglyceride levels were associated with right coronary artery lesions (odds ratio = 1.00; P =.03). The effect of advanced age was small (odds ratio = 1.08; P < .001). Risk factors may be predictive for segmental localization.

Quantitative 82Rb PET/CT: Development and Validation of Myocardial Perfusion Database

The use of myocardial perfusion (82)Rb PET/CT studies continues to increase but its accuracy using database quantification methods for the diagnosis of coronary artery disease (CAD) has not been established. A sex-independent normal database and criteria for abnormality for rest-stress (82)Rb PET/CT myocardial perfusion imaging were developed and validated by evaluation of 281 patients (136 females: mean age +/- SD, 63.3 +/- 13.3 y; 145 males: mean age +/- SD, 63.9 +/- 12.8 y) who underwent a rest-adenosine stress (82)Rb PET/CT study. These patients were divided into 3 groups: (a) healthy group: 30 patients, with <5% likelihood of CAD (low likelihood [LLK]) based on sequential Bayesian analysis; these patients were used to generate the normal distribution; (b) pilot group: 174 patients; these patients were used to determine the optimal criteria for detecting and localizing the perfusion abnormality; and (c) validation group: 76 patients (23 with LLK of CAD and 53 who underwent coronary angiography; these patients were used for prospective validation. Of the 53 patients who underwent coronary angiography, 8 had <50% stenosis and 45 patients had at least one stenosis > or =50% in one major artery. Fifteen patients had single-vessel disease, 17 had double-vessel disease, and 13 had triple-vessel disease. The prospective validation shows a normalcy rate of 78% (18/23) for global CAD. The analyses by individual arteries show a normalcy rate of 96% (22/23) for the left anterior descending coronary artery, 96% for the left circumflex coronary artery (22/23), and 100% for the right coronary artery (23/23). The overall sensitivity for detection of CAD (> or =50% stenosis) was 93% (42/45). The overall specificity for detection of the absence of CAD (< or =50% stenosis) was 75% (6/8). Also, the positive predictive value for global CAD was 95% (42/44), the negative predictive value was 67% (6/9), and the accuracy was 91% (48/53). The quantitative (82)Rb PET/CT database created and validated in this study is highly accurate for the detection and localization of CAD. Physicians should consider using the quantitative output of these algorithms as decision support tools to aid with image interpretation.

Accuracy of stress Tc-99m tetrofosmin myocardial perfusion tomography for the diagnosis and localization of coronary artery disease in women

Earlier studies have suggested a modest accuracy of stress thallium 201 myocardial perfusion imaging (MPI) for the diagnosis of coronary artery disease (CAD) in women. The accuracy of stress MPI with technetium 99m tetrofosmin has not been studied in women. The aim of this study was to assess the accuracy of stress Tc-99m tetrofosmin MPI for the diagnosis and localization of CAD in women. We studied 88 women who underwent exercise or dobutamine stress Tc-99m tetrofosmin tomography and coronary angiography within 3 months. Significant CAD was defined as a stenosis 50% or greater in diameter in at least 1 major epicardial coronary artery. Myocardial perfusion abnormalities were detected in 44 of 53 patients with significant CAD and in 7 of 35 patients without significant CAD (overall sensitivity, 83% [95% confidence interval (CI), 73%-93%]; specificity, 80% [95% CI, 67%-93%]; and accuracy, 82% [95% CI, 74%-90%]). The sensitivity was 72% (18/25) in patients with single-vessel CAD and 93% (26/28) in patients with multivessel CAD. Perfusion abnormalities were detected in 2 or more vascular distributions in 20 of 28 patients with multivessel CAD and in 4 of 60 patients without multivessel CAD (sensitivity for the identification of multivessel CAD, 71% [95% CI, 55%-88%]; specificity, 93% [95% CI, 86%-98%]; and accuracy, 86% [95% CI, 79%-93%]). The sensitivity, specificity, and accuracy were 82%, 84%, and 83%, respectively, for the diagnosis of CAD in the left anterior descending artery; 77%, 84%, and 81%, respectively, for CAD in the right coronary artery; and 74%, 80%, and 78%, respectively, for CAD in the left circumflex artery. Stress Tc-99m tetrofosmin MPI is an accurate noninvasive technique for the diagnosis and localization of CAD in women.

Noninvasive Diagnosis of Coronary Artery Disease in Patients With Diabetes by Dobutamine Stress Real-Time Myocardial Contrast Perfusion Imaging

The aim of this study was to assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) during dobutamine stress in the diagnosis and localization of coronary artery disease (CAD) in patients with diabetes. Myocardial contrast echocardiography is a new technique that allows evaluation of myocardial perfusion. Its utility in diabetic patients has not been defined. Dobutamine-atropine stress test was performed in conjunction with MCPI using Optison or Definity at rest and at peak stress in 128 patients with diabetes and suspected CAD who underwent coronary angiography within 1 month. CAD was defined as > or =50% stenosis in one or more coronary artery. MCPI was considered diagnostic of CAD in the presence of reversible perfusion abnormalities. The normalcy rate of MCPI was additionally determined in 18 asymptomatic nondiabetic patients with low probability. CAD was detected in 101 (79%) patients by angiography. Reversible perfusion abnormalities were detected in 90 patients with and 13 patients without CAD. The overall sensitivity of MCPI was 89% (95% CI 83-95), specificity 52% (33-71), and accuracy 81% (75-88). Reversible abnormalities were detected in two or more vascular distributions in 44 of 56 patients with multivessel CAD and in 8 of 63 patients without (sensitivity 68%, specificity 87%, positive predictive value 84%, and accuracy 79%). Regional sensitivity was 75% (65-85) for left anterior descending CAD, 71% (60-83) for left circumflex, and 67% (55-78) for right CAD. MCPI was normal in 16 of the 18 patients with low clinical probability of CAD (normalcy rate 89%). MCPI is a useful noninvasive technique for the diagnosis and localization of CAD in diabetic patients. The extent of perfusion abnormalities can identify patients with multivessel CAD with a moderate sensitivity and high specificity.

Evaluation of the QT dispersion, Activation recovery interval dispersion, and Recovery time dispersion in myocardial infarction by coronary artery disease location.

Evaluation of the QT dispersion, Activation recovery interval dispersion, and Recovery time dispersion in myocardial infarction by coronary artery disease location.

Integration of clinical and imaging data to predict the presence of coronary artery disease using neural networks

Background: This study tests the hypothesis that a computer-based artificial intelligence method capable of integrating clinical, exercise and imaging data can determine the presence or absence of coronary artery disease (CAD) with predictive accuracy equal to that of standard, expert reader clinical interpretation using imaging, clinical and stress test data. Methods: Patients (Pts; n=102) underwent rest, stress (1 day protocol) gated SPECT technecium-99m-MIBI myocardial perfusion imaging (MPI) and were selected based on availability of high quality MPI and coronary angiography done an average of 60 days after the stress test (range 0–257). All Pts had standard Bruce protocol. Objective parameters (total =20) describing each Pt's stress responses (eg; ST segments, HR, BP, symptoms), clinical status (eg; gender, BMI) and image parameters (eg; SSS,SDS, LV mass, LVEF by Siemens 4DM program;) were used to train an artificial neural network (ANN). Pt's with prior myocardial infarction (N=19) were analyzed separately and since results were unchanged included in the totals. Classification accuracy (CAD, yes vs no) of ANN was compared with that of expert-readers. Extent and location of CAD by ANN also was compared to that of expert readers. A more limited ANN using imaging data only (ANNi) was compared to ANN using all imaging, clinical and stress test parameters (ANNt). Results: Pts were 65+11 yrs, 68% male and 75% had at least one 70% stenosis and so defined as CAD present. ANNt had sensitivity 88% and specificity 65% for CAD vs 80% and 69%, respectively by expert readers (P=ns for sens and spec). Predictive accuracy (PA= TP+TN/all Pts) was comparable (ANNt=81% v experts =77%, p=0.07). However, PA of ANNt (81%) was superior to ANNi (68%, z=2.26, P<0.05) for CAD diagnosis. ANNt and humans were comparable for detecting extent and location of CAD (83,93,92% of 1,2, 3 VD vs 78,82,83%, respectively). Conclusion: The data confirm the hypothesis that an ANN, with training using a probabilistic algorithm, is capable of integrating imaging, clinical and stress test data to predict CAD with accuracy equal to expert humans and superior to images only.

Gated stress-only 99mTc myocardial perfusion SPECT imaging accurately assesses coronary artery disease.

In today's cost containment environment it is important to consider changes to standard protocols which would reduce cost, particularly if there is no significant loss of diagnostic accuracy. The aim of the present study was to assess the usefulness of a gated stress-only Tc sestamibi protocol in comparison to conventional gated dual isotope rest-stress myocardial perfusion single photon emission computed tomography (SPECT) in the detection and localization of coronary artery disease (CAD). Sixty-five consecutive patients (65+/-10 years, 22 women) who had undergone conventional gated perfusion SPECT were chosen retrospectively. Fifty-three of these 65 patients had previous coronary arteriography, 45 with at least one stenosis, eight without stenosis, and 12 of these 65 patients had <5% likelihood of CAD. Three readers interpreted the gated stress-only and dual isotope studies in separate sessions blinded to (1). their previous readings, (2). the interpretation by others, and (3). the angiographic results. Readers used a five-point scale to score their visual and quantitative assessment of perfusion, function and compromised vascular territory. Their average score was used for determination of the accuracy by using receiver operating characteristic (ROC) analysis of the techniques. The areas under ROC curves were determined for the detection of CAD and localization of vascular territories. Fifty-four of these patients had 97 significant stress induced perfusion defects as determined by the CEqual quantitative program. The agreement between protocols for the assessment of reversibility in these 97 defects was analysed. There were no statistically significant differences between dual isotope rest/stress and gated stress-only studies for the detection and localization of CAD. The area under the dual isotope rest/stress ROC curve was 0.78+/-0.07 compared to the area under the gated stress-only ROC curve of 0.80+/-0.06, resulting in P=0.30. For the combined vessels comparison of the area under the dual isotope rest/stress ROC curve was 0.73+/-0.04 versus the area under the gated stress-only ROC curve of 0.74+/-0.04, resulting in P=0.27. Similar non-significant differences were obtained when comparing the area under the dual isotope versus gated stress-only ROC curves for the left anterior descending vascular territory (LAD, 0.61+/-0.08 vs 0.660.08, P=0.14), the left circumflex vascular territory (LCX, 0.82+/-0.07 vs 0.81+/-0.06, P =0.47) or the right coronary vascular territory (RCA, 0.80+/-0.06 vs 0.78+/-0.06, P=0.28). The analysis of the reversibility of stress induced perfusion defects yielded a global agreement between protocols of 93% (kappa=0.42). The differences were due to the expert readers, using the gated stress-only protocol, misinterpreting some patients with attenuation artefacts, subendocardial infarction and functional stunning. These results show that the lower cost gated stress-only myocardial Tc myocardial perfusion SPECT studies are comparable to the conventional dual isotope studies when the clinical question is the detection and localization of coronary artery disease. Nevertheless, we also showed that this approach is limited when attempting to interpret the reversibility of stress induced perfusion defects in patients who exhibit attenuation artefacts, subendocardial infarction and functional stunning.

Quantitative Analysis of Dobutamine-Atropine Stress Echocardiography by Fractional Area Change

Aims: To investigate the usefulness of fractional area change with respect to the diagnosis of coronary artery disease in patients undergoing dobutamine–atropine stress echocardiography. Methods and results: Sixty-eight echogenic patients with a normal left ventricular function referred for coronary angiography underwent dobutamine–atropine stress echocardiography. Measures of fractional area change by segments and by total left ventricular areas were normalized using data from 27 echogenic healthy subjects. The area under the receiver operator characteristics curve indicated a significant diagnostic contribution of fractional area change for both methods ( P <0·05) and sensitivity and specificity for predicting significant coronary stenosis were 80% (95% CI 69–91%) and 76% (95% CI 56–97%) for fractional area change of the total left ventricular area of the two chamber view, comparable to results of conventional wall motion analysis. Segmental fractional area change offered no advantages to that of total left ventricular areas with regard to the diagnosis or localization of coronary artery disease. Conclusion: Fractional area change of the total left ventricular area is an accurate marker of coronary artery disease and may form a basis for quantitative dobutamine–atropine stress echocardiography analysis provided that reproducible endocardial tracings can be obtained. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

Dobutamine technetium-99m tetrofosmin SPECT imaging for the diagnosis of coronary artery disease in patients with limited exercise capacity

Background. Technetium-99m tetrofosmin single photon emission computed tomography (SPECT) imaging is increasingly used in conjunction with exercise and vasodilator stress test as a means of evaluating coronary artery disease (CAD). Dobutamine stress test is an alternative in patients with limited exercise capacity. This study assessed the accuracy of dobutamine-atropine stress tetrofosmin SPECT as a means of diagnosing and localizing CAD. Methods and Results. We studied 124 patients (mean age, 57 ± 12 years; 88 men) with limited exercise capacity and suspected CAD with dobutamine (as much as 40 μg/kg/min)-atropine (as much as 1 mg) Tc-99m tetrofosmin SPECT. Resting images were acquired 24 hours after the stress test. Significant CAD was defined as 50% or greater luminal diameter stenosis in 1 or more major coronary arteries. Myocardial perfusion abnormalities (fixed and/or reversible defects) were detected in 70 of 88 patients with CAD and in 10 of the 36 patients without CAD (sensitivity = 80%, CI, 72 to 87; specificity = 72%, CI, 64 to 80; accuracy = 77%, CI, 70 to 85). Sensitivity and accuracy rates were higher by using the criterion of any defect than by using the criterion of reversible defects only (80% vs 51%, P < .0001; 77% vs 60%, P < .01, respectively). The sensitivity rate was higher in patients with multivessel CAD than in patients with single-vessel CAD (88% vs 63%, P < .05). Patients with multivessel CAD had a larger stress perfusion defect score (4.5 ± 3.1 vs 2.7 ± 2.5, P < .01) than patients with single-vessel CAD. Conclusion. Dobutamine stress Tc-99m tetrofosmin SPECT is a useful method for the diagnosis and localization of CAD in patients with limited exercise capacity. Optimal accuracy of the technique is achieved by using both fixed and reversible perfusion abnormalities for the diagnosis of CAD in patients without an earlier myocardial infarction. (J Nucl Cardiol 2000;7:649-54.)

Accuracy of exercise stress technetium 99m sestamibi SPECT imaging in the evaluation of the extent and location of coronary artery disease in patients with an earlier myocardial infarction

Background. This study assessed the accuracy of exercise methoxy isobutyl isonitrile (MIBI) single photon emission computed tomography (SPECT) in the evaluation of the extent of coronary artery disease (CAD) in patients with an earlier myocardial infarction. Methods and Results. We studied 135 patients (mean age, 57 ± 10 years; 115 men) at a mean of 4.1 years (median, 1 year) after myocardial infarction with symptom-limited bicycle exercise stress and rest MIBI SPECT imaging. Coronary angiography was performed within 3 months. Significant CAD was defined as a stenosis of 50% or larger in luminal diameter in 1 or more major coronary arteries. Myocardial perfusion defects (fixed, reversible, or both) were detected in 107 of the 113 patients with significant CAD and in 10 of the 22 patients without significant CAD (sensitivity, 95%; CI, 91 to 99; specificity, 55%; CI, 46 to 63, and accuracy, 88%; CI, 82 to 94). The specificity rate increased to 73% (CI, 65 to 80) by using only reversible perfusion defects as a means of predicting CAD. Reversible perfusion abnormalities were more frequent in patients with multivessel CAD than in patients with single-vessel CAD (51 of 64 [80%] vs 27 of 49 [55%], P < .01). Myocardial perfusion abnormalities in 2 vascular regions, which is suggestive of multivessel CAD, were detected in 35 of the 64 patients with and in 9 of the 71 patients without multivessel CAD (sensitivity for detecting CAD in more than one vascular region, 55%; CI, 46 to 63, specificity, 87%; CI, 81 to 93, and accuracy, 72%; CI, 64 to 80). The sensitivity rates for the diagnosis of left anterior descending coronary artery, left circumflex, and right coronary artery based on any defect were 80%, 70%, and 63%, respectively. The corresponding specificity rates were 70%, 76%, and 73%, respectively. Conclusions. Exercise MIBI SPECT imaging is an accurate method for the diagnosis and localization of CAD in patients with an earlier myocardial infarction. The technique provides a high specificity and moderate sensitivity for the diagnosis of multivessel CAD on the basis of myocardial perfusion abnormalities in more than 1 vascular region. (J Nucl Cardiol 2000;7:432-8.)

Gender differences in diagnosis and treatment of coronary artery disease from 1981 to 1997. No evidence for the Yentl syndrome

The aim of the present clinical study was to evaluate whether gender-related differences existed as regards the extent and localization of coronary artery lesions in patients with angiographically documented coronary artery disease, and whether these angiographic findings would lead to differences in further management. Over a 16-year period (1981-1997) we evaluated 1894 patients (1526 men, 368 women) with angiographically documented coronary artery disease (luminal stenosis >/=60%). For each patient the coronary angiographic results and subsequent revascularization procedures (percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery) were analysed. The study period was divided into the early angioplasty years (1981 to 1989) and the current angioplasty years (1990-1997). No gender differences in extent and localization of coronary angiographic lesions were observed. In men and women the incidence of single-vessel disease was 42% and 40%, two-vessel disease 27% and 27%, three-vessel disease 26% and 24%, and left main disease 5% and 8%, respectively (P=ns). Localization of disease in men and women was 36% and 39% for the left anterior descending coronary artery, 34% and 32% for the right coronary artery, and 27% and 26% for the left circumflex coronary artery, respectively (P=ns). There was a significant shift from multi-vessel disease towards single-vessel disease in both men and women (both P<0.001). As to subsequent management, a significant gender difference in favour of women was observed (P=0.021). Over time, the number of angioplasty procedures increased significantly from 11.6% to 23.2% for men (P<0.001), and for women from 17.6% to 28.0% (P=0.025), whereas the number of coronary artery bypass procedures decreased in men from 34.9% to 29. 5% (P=0.024) and in women from 42.6% to 30.6% (P=0.019). Referral to angioplasty (n=535) and coronary artery bypass surgery (n=616) in relation to the extent of the disease did not show any gender bias in favour of men. Our angiographic findings did not show significant gender differences as regards the extent and localization of coronary artery disease in patients with angiographically documented coronary artery disease. More importantly, no substantial evidence could be found for under-referral of women to subsequent therapeutic management. Therefore our study questions the presence of Yentl syndrome in the current era.

Abolition of exercise induced positive U-wave after coronary angioplasty: clinical implication

Objective: We prospectively studied the course of exercise induced positive U-wave before and after percutaneous transluminal coronary angioplasty (angioplasty). Background: Negative U-wave in ECG is known to be associated with the myocardial ischemia in the territory of the left anterior descending artery. Positive U-wave needs further evaluation to prove its diagnostic value in localization of coronary artery disease. Method: Twenty patients demonstrated exercise induced positive U-wave from a cohort of 730 patients referred because of chest pain. Exercise was carried to ≥90% of target heart rate. They underwent angiography and subsequent angioplasty for stenosis of 70% or greater. The exercise test was repeated post angioplasty. Careful screening for clinical endpoints and presence of ST segment depression and positive U-wave was done during exercise and the first 3 min of the recovery phase. Results: Fifteen patients had isolated exercise induced U-wave and five had additional ST segment depression of ≥1 mm. Significant stenosis (>70% diameter reduction) of the circumflex artery was seen in 11 (55%) and of the right coronary artery in 9 (45%) patients. Coronary artery stenosis was reduced from 90±2% to 13±1% (mean±S.D.) P<0.001. On repeat of the exercise test U-wave and ST depression disappeared in all 20 individuals. Effort tolerance was improved after angioplasty for a mean duration of 3 min and 38 s, P<0.001. Conclusion: Exercise induced positive U-wave is an infrequent but specific marker of significant single coronary (circumflex or right) artery stenosis. It may lend itself to the detection of restenosis.

Positron emission tomography

Positron emission tomography (PET) is currently the most sophisticated scintigraphic imaging technique developed for in-vivo quantification of cardiac physiology and biochemistry. The state-of-the-art PET technology allows delineation of regional tracer activity with high spatial and temporal resolution. A large number of radiopharmaceuticals have been developed to study myocardial perfusion enabling accurate diagnosis and localization of coronary artery disease (CAD) and energy metabolism. More recently, newer tracers such as radiolabeled catecholamine analogues allow the pre- and postsynaptic evaluation of cardiac autonomic innervation. Metabolic imaging with PET represents currently the gold standard for tissue viability assessment with well-validated diagnostic and prognostic information. F-18 deoxyglucose has been also used in combination with SPECT or coincidence imaging providing comparable clinical information but without need for the expensive and rarely available imaging technology of PET. The assessment of coronary flow reserve is the most sensitive scintigraphic method to i) detect vascular abnormalities before their hemodynamic significance, ii) diagnose and define the extent of CAD, and iii) to monitor the effects of (non)pharmacological intervention on regional and global cardiac flow. C-11 hydroxyephedrine (HED) allows imaging of sympathetic neuronal function. the course of cardiac reinnervation after cardiac transplantation was demonstrated with C-11 HED PET, and preliminary evidence suggests that this technique might provide prognostic information on sympathetic neuronal status in congestive heart failure, too. The functional and prognostic relevance of PET imaging together with the increased availability of lower cost instrumentation imaging will define its future role in the diagnosis, assessment of extent, prognosis and in the therapeutic decision making of cardiac disease.

Clinical application of exercise stress echocardiography: supine bicycle or treadmill?

Although exercise stress echocardiography is currently used to evaluate coronary artery disease (CAD) patients, the best exercise methodology is still undefined. The objectives of the study were: (1) to compare supine bicycle stress echocardiography (SBSE) and treadmill in the evaluation of CAD; and (2) to define, in normal subjects, the different behavior of factors determining MVO 2 with treadmill and SBSE. We selected 10 male patients with CAD (group A), and 10 male control subjects (group B). Each patient underwent SBSE and treadmill testing in random order. We studied heart rate, systolic blood pressure, heart rate × systolic blood pressure, and end-diastolic and end-systolic volume indexes. In group A, we also studied wall motion score index (according to the American Society of Echocardiography) and in group B, systolic blood pressure/end-systolic volume index. The results were as follows: Group A: SBSE resulted in significantly lower work load, heart rate, and significantly higher systolic blood pressure, heart rate × systolic blood pressure, end-diastolic volume index, end-systolic volume index, and wall motion score index. SBSE showed wall motion abnormalities in each patient, whereas treadmill did not detect wall motion abnormalities in 4 patients (3 single-vessel; 1 multivessel); of the other 6 patients, 2 showed a lower wall motion score index and 4 did not show any difference in left ventricle kinetics with the 2 methodologies of exercise. Mean acquisition time for postexercise images was 72 ± 6 seconds. Group B: SBSE resulted in lower work load, heart rate, heart rate × systolic blood pressure, systolic blood pressure/end-systolic volume index, and higher end-diastolic volume index and end-systolic volume index. Systolic blood pressure was similar with SBSE and treadmill testing. In conclusion, our experience suggests SBSE is a highly accurate diagnostic tool for evaluating CAD compared with treadmill testing; the maximum cardiovascular performance can be achieved with lower values of heart rate, suggesting the echo test is more feasible. Treadmill testing could lose important information about the existence, extension, and location of CAD; in contrast, SBSE detects even small, quickly reversible wall motion abnormalities.

Passive Acoustic Imaging for Non-invasive Detection and Localization of Coronary Artery Disease: Detection Threshold in an In-Vitro Model

Passive Acoustic Imaging for Non-invasive Detection and Localization of Coronary Artery Disease: Detection Threshold in an In-Vitro Model

Passive acoustic imaging for non-invasive detection and localization of coronary artery disease: detection threshold in an in-vitro model

Passive acoustic imaging for non-invasive detection and localization of coronary artery disease: detection threshold in an in-vitro model