Management Of Coronary Artery Disease Research Articles

Preprocedural Anxiety in the Transradial Cardiac Catheterization Era.

Transradial cardiac catheterization is increasingly being used for the management of coronary artery disease given the low risk of procedural discomfort and complications with this approach. However, the evidence relating to preprocedural anxiety levels in these patients is scarce. The aim of this study was to evaluate the anxiety levels and the predictors of anxiety in patients undergoing transradial cardiac catheterization procedures. Data were collected using a self-administered survey. Anxiety was measured using the Spielberg's State-Trait Anxiety Inventory questionnaire. Multiple regression analysis was used to identify whether gender, age, family history of heart disease, smoking status, history of depression, and trait anxiety scores were predictors of preprocedural anxiety. A total of 198 patients participated in this study. More than half of the patients (53.5%) were classified as having a high state anxiety level. The mean (SD) preprocedural trait and state anxiety scores were 35.34 (9.8) and 36.43 (11.4), respectively. Female patients, those younger than 65 years, current smokers, and those with a family history of heart disease, a history of depression, and a history of anxiety had significantly higher anxiety scores. Having high trait anxiety scores was the only predictor of preprocedural anxiety. Although the transradial approach has a low procedural risk and causes less discomfort to the patient, anxiety persists in more than 50% of patients, with trait anxiety being the best predictor. Nurses should therefore try to decrease anxiety levels in the preprocedural phase to minimize postprocedural adverse outcomes in this group of patients.

Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity.

Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.

Complex interventions in the failing heart.

Heart failure is a complex clinical syndrome with a substantial disease burden. We aim to review the interventional aspects of management of advanced heart failure, focusing on the role of management of coronary artery disease, valvular heart disease, and mechanical circulatory support. The patients with coronary artery disease and heart failure requiring revascularization are at higher risk than the rest of the general population. Coronary artery bypass grafting or percutaneous intervention can be used depending on varied patient characteristics and coronary anatomy. Transcatheter aortic valve implantation, Mitraclip and transcatheter ventricular restoration help in tackling the valvular and left ventricular remodeling concerns often seen in this patient population. Temporary hemodynamic circulatory support helps stabilizing patients in cardiogenic shock while long-term support can help bridge them to more definitive therapies. The management strategies in this disease state are ever evolving with robust evidence coming in support of interventional therapies whenever deemed appropriate. It is the multidisciplinary patient-centered approach, which yields maximum benefit out of these complex interventions.

Gender Disparities on Access to Care and Coronary Disease Management.

Mortality decline in women to a lesser extent than in men with coronary artery disease (CAD) has provoked a bigger interest in some already existing dilemmas and questions. Many studies carried out in the past three decades did not provide us with precise conclusions. Moreover, various challenges in the prevention, diagnosis, treatment and outcome of CAD in women are still remaining. The meta-analysis and the systematic review conducted in the last years have offered novel approaches to understanding CAD gender disparities in access to care and coronary disease management in women, but women are more likely to experience less favorable short- and long-term outcomes than men do. The reasons for these findings should lie in several known segments in the CAD pathophysiological mechanisms different in women and ultimately leading to a lower quality of care. Clinical presentation in women, which is often characterized by atypical chest pain and a higher prevalence of non-obstructive CAD when evaluated invasively, places women to the false-negative diagnosis of CAD and influences inadequate access to care. Clinical presentation and diagnostic methods, as well as the appropriate treatment options insufficiently examined in women, need to be better defined. The traditional CAD risk factors have a greater impact on women than on men. Unique CAD risk factors only seen in women, have recently been recognized with more attention. However, it is important to note that even in women with obstructive CAD and typical clinical presentation, invasive therapy and pharmacologic therapy are not always implemented as recommended by guidelines as in men. Women are underrepresented in CAD trials, and in current guidelines, gender differences in CAD management have not yet been justified. The underestimation of the risk of CAD in women, followed by its underdiagnosis and undertreatment, might be one of the reasons for a worse prognosis in women in comparison with men.

Depressive Symptoms and Health-Related Quality of Life in Patients with Cardiovascular Diseases Attending a Tertiary Care Hospital, Puducherry-A Cross-Sectional Study.

Background Globally, coronary artery disease (CAD) was the leading cause of health losses. The emergence of revascularization has brought a major change in the management of CAD. Depression and cardiovascular diseases (CVD) are the two highly prevalent noncommunicable diseases (NCD), which lead to poor quality of life and high socio-economic loss for the patient. The rate of depressive episodes was higher in CAD population in comparison to population with other heart problems. Objectives The primary objective of the current study is to determine the proportion of those with depressive symptoms through Patient Health Questionnaire-9 (PHQ-9) among CAD patients in a tertiary care public hospital. Methods It was a cross-sectional analytical design, which assess the percentage of patients with depressive symptoms among CAD patients, using a pretested, semistructured questionnaire. The PHQ-9 and EuroQoL five-dimensional three-level (EQ-5D-3L) questionnaire, a quality-of-life instrument (five items), were used, which was validated in the Tamil version. Statistical Analysis Categorical variables was expressed as proportion. We used Chi-square as a statistical test to calculate the p value and risk estimation with 95% CI. Results Out of 541 patients, 159 (30%) patients had mild-to-moderate depressive symptoms, of which 144 (89%) participants were greater than 50 years. In EQ-5D-3L, around one-third of the participants reported pain or discomfort and anxiety or depression. Conclusion The study concludes that the assessment of health-related quality of life (HRQoL) is becoming increasingly important in the management of CAD patients. Studies have shown that depression predicts subsequent quality of life, while others have shown that HRQoL is a risk factor for ongoing depression. Treatment of depression may improve subsequent physical HRQoL; hence, it is vital to address both during their follow-up to improve outcomes among patients with CAD.

Optimising physiological endpoints of percutaneous coronary intervention.

Invasive coronary physiology to select patients for coronary revascularisation has become established in contemporary guidelines for the management of stable coronary artery disease. Compared to revascularisation based on angiography alone, the use of coronary physiology has been shown to improve clinical outcomes and cost efficiency. However, recent data from randomised controlled trials have cast doubt upon the value of ischaemia testing to select patients for revascularisation. Importantly, 20-40% of patients have persistence or recurrence of angina after angiographically successful percutaneous coronary intervention (PCI). This state-of-the-art review is focused on the transitioning role of invasive coronary physiology from its use as a dichotomous test for ischaemia with fixed cut-points, towards its utility for real-time guidance of PCI to optimise physiological results. We summarise the contemporary evidence base for ischaemia testing in stable coronary artery disease, examine emerging indices which allow advanced physiological guidance of PCI, and discuss the rationale and evidence base for post-PCI physiological assessments to assess the success of revascularisation.

Design consideration of compact cardiac TOF-PET systems: a simulation study

Myocardial perfusion imaging (MPI) with PET plays a vital role in the management of coronary artery disease. High sensitivity systems can contribute to maximizing the potential value of PET MPI; therefore, we have proposed two novel detector arrangements, an elliptical geometry and a D-shape geometry, that are more sensitive and more compact than a conventional large-bore cylindrical geometry. Here we investigate two items: the benefits of the proposed geometries for cardiac imaging; and the effects of scatter components on cardiac PET image quality. Using the Geant4 toolkit, we modeled four time-of-flight (TOF) PET systems: an 80 cm diameter cylinder, a 40 cm diameter cylinder, a compact ellipse, and a compact D-shape. Spatial resolution and sensitivity were measured using point sources. Noise equivalent count rate and image quality were examined using an anthropomorphic digital chest phantom. The proposed geometries showed higher sensitivity and better count rate characteristics with a fewer number of detectors than the conventional large-bore cylindrical geometry. In addition, we found that the increased intensity of the scatter components was a big factor affecting the contrast in defect regions for such a compact geometry. It is important to address the issue of the increased intensity of the scatter components to develop a high-performance compact cardiac TOF PET system.

Impact of Coronary Artery Disease and Percutaneous Coronary Intervention on Transcatheter Aortic Valve Implantation.

Introduction The prevalence of coronary artery disease (CAD) detected in preoperative work-up for transcatheter aortic valve implantation (TAVI) is high. Instead, the management of a concomitant CAD remains unclear. We evaluate the impact of CAD and percutaneous coronary intervention (PCI) on TAVI procedures. Materials and Methods A retrospective study was conducted on 1336 consecutive patients who underwent TAVI in Toulouse University Hospital, Rangueil, France. The studied population was divided into 2 groups: CAD-TAVI group and No CAD-TAVI group. Then, the CAD-TAVI group was segregated into 2 subgroups: PCI-TAVI group and No PCI-TAVI group. In-hospital adverse clinical outcomes were assessed in each group. Results Pre-TAVI work-up revealed significant CAD in 36% of 1030 patients eligible for inclusion in the study. The overall prevalence of in-hospital death, stroke, major or life-threatening bleeding, minor bleeding, major vascular complications, minor vascular complications, pacemaker implantation, and acute kidney injury was 2.7%, 2.4%, 2.8%, 3.6%, 3.9%, 7.5%, 12.5%, and 2.7%, respectively. Among the studied population, 55% were admitted to the cardiac care unit. No significant statistical difference was observed between groups. Discussion. CAD-TAVI population was not more likely to develop in-hospital adverse clinical outcomes post-TAVI procedure compared to others. Also, no significant difference regarding in-hospital death was observed. In parallel, performing PCI prior to TAVI did not increase the risk of in-hospital death and complications. The difference in terms of the distribution of antithrombotic regimen may explain the higher prevalence of bleeding events in the PCI-TAVI group. Conclusion This study provides direct clinical relevance useful in daily practice. No negative impact has been attributed to the presence of a concomitant CAD and/or preoperative PCI on the TAVI hospitalization period.

A Study to Assess Awareness Levels and Status of Lipid Parameters in the Subjects with Coronary Artery Disease in Tertiary Care Setup in a Rural Area

Background:-. Among the various cardiovascular diseases, Coronary artery disease is one of the majoretiology of mortality and morbidity in the world wide population. It is a prevalence in mainly older adultsand exists in the entire health context. The CAD prevalence was strongly associated with various lipidparameters such as cholesterol and different lipoprotein fraction, which contributed as a major factor for theprogression of CAD. In spite of various therapeutic advances, so for safe and effective management of CAD,there are requirements for consideration of risk/benefits and goals of care.Objective: To determine the current level of knowledge of the symptoms and duration of diseases and alsocomparison of lipid parameters in cases and control.Material and Methods:-The study was a case control observational study conducted in the department ofbiochemistry, SBKSMI& RC. A total of 200 subjects of 100 Coronary artery disease (CAD) and 100 healthycontrol were enrolled to assess lipid parameter and duration of diseases.Result: - There were 82% male and 18% female in case group and CAD caused majorly by the anginawhich was 65% and in the symptom of duration, majority of people aware with their symptoms in less than1 months. In the measurement of dyslipidemia there was significantly higher in atherogenic component i.e.LDL-C and anti atherogenic component i.e. HDL-C was also higher and found significant.Conclusion: - The majority of subjects who were suffering from CAD were males compared to females.Most of the patients from a rural areas so they had a chest pain comparison to heart attack and found highlysignificant with lipid parameters.

Aortic Valve Disease and Associated Complex CAD: The Interventional Approach.

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

The Management of Coronary Artery Disease in Ethiopia: Emphasis on Revascularization.

Cardiovascular diseases are number one cause of death worldwide. Over half of the cardiovascular diseases, 51%, are due to coronary artery disease. Coronary artery disease is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial coronary arteries. Rupture of the fibrous cap of the plaque causes the majority of the deaths due to myocardial infarction. Angina pectoris is a discomfort in the chest or adjacent areas caused by myocardial ischemia usually precipitated by exertion. In acute coronary syndrome, the chest discomfort is either of low threshold or appears at rest and when it evolves on the background of established angina pectoris, the discomfort becomes more frequent and prolonged. Exercise electrocardiography which has been the most frequently used non-invasive test to diagnose obstructive coronary artery disease is currently shown to have inferior diagnostic performance compared with diagnostic imaging tests. The pivotal tests in patients presenting with clinical features of acute coronary syndrome are electrocardiography and determination of serum troponin I and/or T. Revascularization is the mainstay of treatment in patients with acute coronary syndrome. In chronic coronary syndrome, on top of optimal medical treatment, revascularization reduces mortality in:- 1) left main stenosis, 2) three-vessel coronary artery disease, particularly with ejection fraction of less than 40%, 3) two vessel disease with more than 75% stenosis of the proximal left anterior descending coronary artery disease.

A 2-year investigation of the impact of the computed tomography-derived fractional flow reserve calculated using a deep learning algorithm on routine decision-making for coronary artery disease management.

This study aims to investigate the safety and feasibility of using a deep learning algorithm to calculate computed tomography angiography-based fractional flow reserve (DL-FFRCT) as an alternative to invasive coronary angiography (ICA) in the selection of patients for coronary intervention. Patients (N = 296) with symptomatic coronary artery disease identified by coronary computed tomography angiography (CTA) with stenosis over 50% were retrospectively enrolled from a single centre in this study. ICA-guided interventions were performed in patients at admission, and DL-FFRCT was conducted retrospectively. The influences on decision-making by using DL-FFRCT and the clinical outcome were compared to those of ICA-guided care for symptomatic CAD at the 2-year follow-up evaluation. Two hundred forty-three patients were evaluated. Up to 72% of diagnostic ICA studies could have been avoided by using a DL-FFRCT value > 0.8 as a cut-off for intervention. A similar major adverse cardiovascular event (MACE) rate was observed in patients who underwent revascularisation with a DL-FFRCT value ≤ 0.8 (2.9%) compared to that of ICA-guided interventions (3.3%) (stented lesions with ICA stenosis > 75%) (p = 0.838). DL-FFRCT can reduce the need for diagnostic coronary angiography when identifying patients suitable for coronary intervention. A low MACE rate was found in a 2-year follow-up investigation. • Seventy-two percent of diagnostic ICA studies could have been avoided by using a DL-FFRCT value > 0.8 as a cut-off for intervention. • Coronary artery stenting based on the diagnosis by using a 320-detector row CT scanner and a positive DL-FFRCT value could potentially be associated with a lower occurrence rate of major adverse cardiovascular events (2.9%) within the first 2 years. • A low event rate was found when intervention was performed in tandem lesions with haemodynamic significance based on DL-FFRCT < 0.8 as a cut-off value.

Thirteen-year trends in cardiovascular risk in men and women with chronic coronary syndrome.

To examine combined and sex-specific temporal changes in risks of adverse cardiovascular events and coronary revascularization in patients with chronic coronary syndrome undergoing coronary angiography. We included all patients with stable angina pectoris and coronary artery disease examined by coronary angiography in Western Denmark from 2004 to 2016. Patients were stratified by examination year interval: 2004-2006, 2007-2009, 2010-2012, and 2013-2016. Outcomes were 2-year risk of myocardial infarction, ischaemic stroke, cardiac death, and all-cause death estimated by adjusted incidence rate ratios using patients examined in 2004-2006 as reference. A total of 29 471 patients were included, of whom 70% were men. The 2-year risk of myocardial infarction [2.8% vs. 1.9%, adjusted incidence rate ratio 0.65, 95% confidence interval (CI) 0.53-0.81], ischaemic stroke (1.8% vs. 1.1%, adjusted incidence rate ratio 0.48, 95% CI 0.37-0.64), cardiac death (2.1% vs. 0.9%, adjusted incidence rate ratio 0.38, 95% CI 0.29-0.51), and all-cause death (5.0% vs. 3.6%, adjusted incidence rate ratio 0.65, 95% CI 0.55-0.76) decreased from the first examination interval (2004-2006) to the last examination interval (2013-2016). Coronary revascularizations also decreased (percutaneous coronary intervention: 51.6% vs. 42.5%; coronary artery bypass grafting: 24.6% vs. 17.5%). Risk reductions were observed in both men and women, however, women had a lower absolute risk. The risk for adverse cardiovascular events decreased substantially in both men and women with chronic coronary syndrome from 2004 to 2016. These results most likely reflect the cumulative effect of improvements in the management of chronic coronary artery disease.

The impact of vildagliptin on the daily glucose profile and coronary plaque stability in impaired glucose tolerance patients with coronary artery disease: VOGUE\u2014A multicenter randomized controlled trial

BackgroundThe impact of reduction in glycemic excursion on coronary plaques remains unknown. This study aimed to elucidate whether a dipeptidyl peptidase 4 inhibitor could reduce the glycemic excursion and stabilize the coronary plaques compared with conventional management in coronary artery disease (CAD) patients with impaired glucose tolerance (IGT).MethodsThis was a multicenter, randomized controlled trial including CAD patients with IGT under lipid-lowering therapy receiving either vildagliptin (50 mg once a day) or no medication (control group) regarding glycemic treatment. The primary endpoint was changes in the minimum fibrous cap thickness and lipid arc in non-significant native coronary plaques detected by optical coherence tomography at 6 months after intervention. Glycemic variability expressed as the mean amplitude of glycemic excursion (MAGE) measured with a continuous glucose monitoring system was evaluated before and 6 months after intervention.ResultsA total of 20 participants with 47 lesions were allocated to either the vildagliptin group (10 participants, 22 lesions) or the control group (10 participants, 25 lesions). The adjusted difference of mean changes between the groups was − 18.8 mg/dl (95% confidence interval, − 30.8 to − 6.8) (p = 0.0064) for the MAGE (vildagliptin, − 20.1 ± 18.0 mg/dl vs. control, 2.6 ± 12.7 mg/dl), − 22.8° (− 40.6° to − 5.1°) (p = 0.0012) for the mean lipid arc (vildagliptin, − 9.0° ± 25.5° vs. control, 15.8° ± 16.8°), and 42.7 μm (15.3 to 70.1 μm) (p = 0.0022) for the minimum fibrous cap thickness (vildagliptin, 35.7 ± 50.8 μm vs. control, − 15.1 ± 25.2 μm).ConclusionsVildagliptin could reduce the MAGE at 6 months and may be associated with the decreased lipid arc and increased minimum FCT of the coronary plaques in CAD patients with IGT as compared with the control group. These findings may represent its potential stabilization effect on coronary plaques, which are characteristic in this patient subset.Trial registration Registered in the UMIN clinical trial registry (UMIN000008620), Name of the registry: VOGUE trial, Date of registration: Aug 6, 2012, URL: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000010058

Gender differences in screening for glucose perturbations, cardiovascular risk factor management and prognosis in patients with dysglycaemia and coronary artery disease: results from the ESC-EORP EUROASPIRE surveys

BackgroundGender disparities in the management of dysglycaemia, defined as either impaired glucose tolerance (IGT) or type 2 diabetes (T2DM), in coronary artery disease (CAD) patients are a medical challenge. Recent data from two nationwide cohorts of patients suggested no gender difference as regards the risk for diabetes-related CV complications but indicated the presence of a gender disparity in risk factor management. The aim of this study was to investigate gender differences in screening for dysglycaemia, cardiovascular risk factor management and prognosis in dysglycemic CAD patients.MethodsThe study population (n = 16,259; 4077 women) included 7998 patients from the ESC-EORP EUROASPIRE IV (EAIV: 2012–2013, 79 centres in 24 countries) and 8261 patients from the ESC-EORP EUROASPIRE V (EAV: 2016–2017, 131 centres in 27 countries) cross-sectional surveys. In each centre, patients were investigated with standardised methods by centrally trained staff and those without known diabetes were offered an oral glucose tolerance test (OGTT). The first of CV death or hospitalisation for non-fatal myocardial infarction, stroke, heart failure or revascularization served as endpoint. Median follow-up time was 1.7 years. The association between gender and time to the occurrence of the endpoint was evaluated using Cox survival modelling, adjusting for age.ResultsKnown diabetes was more common among women (32.9%) than men (28.4%, p < 0.0001). OGTT (n = 8655) disclosed IGT in 17.2% of women vs. 15.1% of men (p = 0.004) and diabetes in 13.4% of women vs. 14.6% of men (p = 0.078). In both known diabetes and newly detected dysglycaemia groups, women were older, with higher proportions of hypertension, dyslipidaemia and obesity. HbA1c was higher in women with known diabetes. Recommended targets of physical activity, blood pressure and cholesterol were achieved by significantly lower proportions of women than men. Women with known diabetes had higher risk for the endpoint than men (age-adjusted HR 1.22; 95% CI 1.04–1.43).ConclusionsGuideline-recommended risk factor control is poorer in dysglycemic women than men. This may contribute to the worse prognosis in CAD women with known diabetes.

Coronary CT Angiography Guided Medical Therapy in Subclinical Atherosclerosis.

The goals of primary prevention in coronary atherosclerosis are to avoid sudden cardiac death, myocardial infarction or the need for revascularization procedures. Successful prevention will rely on accurate identification, effective therapy and monitoring of those at risk. Identification and potential monitoring can be achieved using cardiac computed tomography (CT). Cardiac CT can determine coronary artery calcification (CAC), a useful surrogate of coronary atherosclerosis burden. Cardiac CT can also assess coronary CT angiography (CCTA). CCTA can identify arterial lumen narrowing and highlight mural atherosclerosis hitherto hidden from other anatomical approaches. Herein we consider the role of CCTA and CAC-scoring in subclinical atherosclerosis. We explore the use of these modalities in screening and discuss data that has used CCTA for guiding primary prevention. We examine therapeutic trials using CCTA to determine the effects of plaque-modifying therapies. Finally, we address the role of CCTA and CAC to guide therapy as defined in current primary prevention documents. CCTA has emerged as an essential tool in the detection and management of clinical coronary artery disease. To date, its role in subclinical atherosclerosis is less well defined, yet with modern CT scanners and continued pharmacotherapy development, CCTA is likely to achieve a more prominent place in the primary prevention of coronary atherosclerosis.

Stress CMR in Known or Suspected CAD: Diagnostic and Prognostic Role.

The recently published 2019 guidelines on chronic coronary syndromes (CCS) focus on the need for noninvasive imaging modalities to accurately establish the diagnosis of coronary artery disease (CAD) and assess the risk of clinical scenario occurrence. Appropriate patient management should rely on controlling symptoms, improving prognosis, and guiding each therapeutic strategy as well as monitoring disease progress. Among the noninvasive imaging modalities, cardiovascular magnetic resonance (CMR) has gained broad acceptance in past years due to its unique features in providing a complete assessment of CAD through data on cardiac anatomy and function and myocardial viability, with high spatial and temporal resolution and without ionizing radiation. In detail, evaluation of the presence and extent of myocardial ischemia through stress CMR (S-CMR) has shown a high rule-in power in detecting functionally significant coronary artery stenosis in patients suspected of CCS. Moreover, S-CMR technique may add significant prognostic value, as demonstrated by different studies which have progressively evidenced the valuable power of this multiparametric imaging modality in predicting adverse cardiac events. The latest scientific progress supports a greater expansion of S-CMR with improvement of quantitative myocardial perfusion analysis, myocardial strain, and native mapping within the same examination. Although further study is warranted, these techniques, which are currently mostly restricted to the research field, are likely to become increasingly prevalent in the clinical setting with the scope of increasing accuracy in the selection of patients to be sent to invasive revascularization. This review investigates the diagnostic and prognostic role of S-CMR in the context of CAD, by analysing a strong, long-standing, scientific evidence together with an appraisal of new advanced techniques which may potentially enrich CAD management in the next future.

Cost-Effectiveness of Coronary Artery Calcium Scoring in People With a Family History of Coronary Disease

ObjectivesTo assess the cost effectiveness of coronary artery calcium (CAC) compared with traditional risk factor–based prediction alone in those with an family history of premature coronary artery disease (FHCAD). BackgroundThe use of CAC scoring to guide primary prevention statin therapy in those with a FHCAD is inconsistently recommended in guidelines, and usually not reimbursed by insurance. MethodsA microsimulation model was constructed in TreeAge Healthcare Pro using data from 1,083 participants in the CAUGHT-CAD (Coronary Artery Calcium Score: Use to Guide Management of HerediTary Coronary Artery Disease) trial. Outcomes assessed were quality-adjusted life years (QALYs): cost-effectiveness was assessed over a 15-year time horizon from the perspective of the US health care sector using real-world statin prescribing, accounting for the effect of knowledge of subclinical disease on adherence to guideline-directed therapies. Costs were assessed in 2020 USD, with discounting undertaken at 3%. ResultsStatins were indicated in 45% of the cohort using the CAC strategy and 27% using American College of Cardiology/American Heart Association (2019) treatment strategies. Compared with applying a statin treatment threshold of 7.5%, the CAC strategy was more costly ($145) and more effective (0.0097 QALY) with an incremental cost-effective ratio (ICER) of $15,014/QALY. CAC ICER was driven by CAC acquisition and statin prescription cost and improved with certain patient subgroups: male, age >60 years, and 10-year risk pooled cohort equation risk ≥7.5%. CAC scanning of low-risk patients (10-year risk <5%) or those 40 to 50 years of age was not cost-effective. ConclusionsSystematic CAC screening and treatment of those with FHCAD and subclinical disease was more cost-effective than management using statin treatment thresholds, in the US health care system.

Key Issues in the Statistical Interpretation of Randomized Clinical Trials

Traditional statistical analyses of randomized clinical trials typically use P values within a null hypothesis significance testing paradigm. Clinical adoption of randomized trials results, by guideline writers and individual clinicians, are often unequivocally determined by a deification of P < 0.05. Although the many limitations and large potential for misinterpretations with this approach have long been appreciated in the statistical literature, these issues are less frequently considered in the clinical literature. Discussions of these limitations might be viewed as esoteric, so that many cardiovascular specialists believe they are of little clinical importance. Using contemporary examples from the cardiovascular literature the potential, interpretative pitfalls in assessing “negative,” “positive,” and “noninferiority” trials are discussed accompanied by caveats on the statistical issues of the strength of the evidence and researcher degrees of freedom. Considerations such as effect size overestimation, robustness of results, statistical power issues, pitfalls in noninferiority trial interpretation, researcher degrees of freedom, and strength of evidence are discussed, using examples from well known trials in the areas of surgical and interventional management of coronary artery disease, heart failure management, and pharmacotherapy. The examples provided illustrate how even landmark trials in prestigious journals can present statistical problems that substantially undermine their conclusions or even make them unreliable. The goal of this article is to help clinicians more accurately reflect on and interpret research findings, by emphasizing the importance of the choice and interpretation of some of the current statistical techniques used in the analyses of randomized clinical trials.

Rationale, design, and baseline characteristics of Chinese registry in early detection and risk stratification of coronary plaques (C-STRAT) study.

Rationale, design, and baseline characteristics of Chinese registry in early detection and risk stratification of coronary plaques (C-STRAT) study.