Non-invasive Testing For Ischemia Research Articles

From chest pain to coronary functional testing: Clinical and economic impact of coronary microvascular dysfunction

BackgroundCoronary functional testing to formally diagnose coronary microvascular dysfunction (CMD) reduces cardiovascular events and alleviates angina. This study aims to investigate the extensive and complex journey that patients with CMD undergo, from the onset of chest pain to eventual diagnosis. MethodsData from the Coronary Microvascular Disease Registry (CMDR) were analyzed, including information on the date of first documentation of chest pain, number of non-invasive and invasive tests the patient underwent, emergency department visits, and hospitalizations. In addition, we estimated the total cost per patient. A total of 61 patients with CMD diagnosis were included in this analysis. ResultsMost patients in our cohort were older than 50 years of age. The median time from initial chest pain symptoms to diagnosis was 0.62 (interquartile range [IQR]: 0.06–2.96) years. During this period, patients visited the emergency department a median of 1.0 (IQR: 0.0–2.0) times. Diagnostic tests included 3.0 (IQR: 2.0–6.0) electrocardiograms, 3.0 (IQR: 0.0–6.0) high-sensitivity troponin tests, and 1.0 (IQR: 1.0–2.0) echocardiograms. Prior to diagnosis of CMD, 13 (21.3 %) patients had left heart catheterization without coronary functional testing. Non-invasive testing for ischemia was conducted in 43 (70.5 %) patients. Alternative non-cardiac diagnoses were given to 11 (18.0 %) patients during the diagnostic process, with referrals made to gastroenterology for 16 (26.2 %) and pulmonology for 10 (16.4 %) patients. The cost was almost $2000/patient. ConclusionTimely identification of CMD offers promising opportunities for prompt symptom alleviation, accompanied by reduced visits to the emergency department, cardiovascular testing, invasive medical procedures, and consequently reduced healthcare expenses.

Left bundle branch block cardiomyopathy: an intriguing and defiant entity from diagnosis to treatment

Abstract Introduction and objectives Left bundle branch block cardiomyopathy (LBBB-CM) is an increasingly recognized entity, where electromechanical dyssynchrony seems to play a central role in left ventricular dysfunction (LVD) development. This is a challenging and scarcely studied topic, as causality dilemma between LBBB and LVD is still unsolved. Our aim is to increase current evidence on the subject by analyzing a population of idiopathic LBBB patients (pts) who developed, at some point, LVD not explained by other causes. Methods Retrospective study of LBBB adult pts screened from a large tertiary care hospital electrocardiographic database from 2011 to 2017. After careful evaluation, only possible LBBB-CM pts with serial follow-up (FU) echocardiographic and clinical data were included in the analysis. Results 53 pts were identified as possible LBBB-CMP. At baseline, 44% presented left ventricular ejection fraction (LVEF)>50%, while 56% had LVD. 51% were female and mean age at first-ever LBBB report was 59 years-old. All cohort presented echocardiographic mechanical desynchrony, and additional testing to exclude other causes of LVD (non-invasive ischemia testing in 78%; coronariography in 68%; cardiac magnetic resonance in 38%). Median FU time was 10 years. Worst-LVD was reported as severe in 49% of pts, moderate in 23% and mild in 28%. Median time-to-dysfunction in those with initial LVEF>50% was 8 years. 77% of pts presented heart-failure (HF) symptoms. 40% and 42% presented at least 1 CV event and CV hospitalization, respectively. Most events and/or hospitalizations were due to acute decompensated HF. 2 CV deaths were observed. Cardiac resynchronization therapy (CRT) devices were implanted in 47% of pts. All presented clinical improvement after implantation, and LVEF significantly increased (pre-CRT median LVEF of 24% vs 48% post-CRT; p<0.001). When comparing pts with vs without CRT (Figure 1), better LVEF improvements were achieved in CRT group (median LVEF improvement of 27% in CRT vs 11%; p<0.001). Repeating the latter analysis in pts who only presented at least moderate dysfunction, higher LVEF increase was also reported in CRT group (median LVEF improvement of 27% in CRT pts vs 14%; p=0.002), and significantly more CRT pts recovered LV function (50% CRT vs 14% non-CRT; p=0.028). Notably, no differences were found in rates of medical HF therapy between groups (p=1). Conclusion Our data shows LBBB-CM as a diagnosis of exclusion, where careful evaluation of other LVD etiologies should be performed and discarded. We highlight important morbidity rates in this population, namely HF hospitalizations, as well as the apparently critical role of CRT implantation in these pts. All our CRT pts responded excellently to the therapy. Thus, our study raises awareness to the emerging question of whether this entity can be reversed after LBBB correction with CRT and if early intervention would be desirable.Figure 1

Invasive Functional Assessment of Coronary Artery Disease in Patients with Severe Aortic Stenosis in the TAVI Era.

Coronary artery disease (CAD) is a common finding in patients suffering from aortic valve stenosis (AS), with a prevalence of over 50% in patients 70 years of age or older. Transcatheter aortic valve intervention (TAVI) is the standard treatment option for patients with severe AS and at least 75 years of age. Current guidelines recommend percutaneous coronary intervention (PCI) in patients planned for TAVI with stenoses of >70% in the proximal segments of non-left main coronary arteries and in >50% of left main stenoses. While the guidelines on myocardial revascularization clearly recommend functional assessment of coronary artery stenoses of less than 90% in the absence of non-invasive ischemia testing, a statement regarding invasive functional testing in AS patients with concomitant CAD is lacking in the recently published guideline on the management of valvular heart disease. This review aims to provide an overview of the hemodynamic background in AS patients, discusses and summarizes the current evidence of invasive functional testing in patients with severe AS, and gives a future perspective on the ongoing trials on that topic.

Machine learning models of clinically relevant biomarkers for the prediction of stable obstructive coronary artery disease.

BackgroundIn patients with suspected obstructive coronary artery disease (CAD), evaluation using a pre-test probability model is the key element for diagnosis; however, its accuracy is controversial. This study aimed to develop machine learning (ML) models using clinically relevant biomarkers to predict the presence of stable obstructive CAD and to compare ML models with an established pre-test probability of CAD models.MethodsEight machine learning models for prediction of obstructive CAD were trained on a cohort of 1,312 patients [randomly split into the training (80%) and internal validation sets (20%)]. Twelve clinical and blood biomarker features assessed on admission were used to inform the models. We compared the best-performing ML model and established the pre-test probability of CAD (updated Diamond-Forrester and CAD consortium) models.ResultsThe CatBoost algorithm model showed the best performance (area under the receiver operating characteristics, AUROC, 0.796, and 95% confidence interval, CI, 0.740–0.853; Matthews correlation coefficient, MCC, 0.448) compared to the seven other algorithms. The CatBoost algorithm model improved risk prediction compared with the CAD consortium clinical model (AUROC 0.727; 95% CI 0.664–0.789; MCC 0.313). The accuracy of the ML model was 74.6%. Age, sex, hypertension, high-sensitivity cardiac troponin T, hemoglobin A1c, triglyceride, and high-density lipoprotein cholesterol levels contributed most to obstructive CAD prediction.ConclusionThe ML models using clinically relevant biomarkers provided high accuracy for stable obstructive CAD prediction. In real-world practice, employing such an approach could improve discrimination of patients with suspected obstructive CAD and help select appropriate non-invasive testing for ischemia.

Quality and safety of coronary computed tomography angiography at academic and non-academic sites: insights from a large European registry (ESCR MR/CT Registry).

To compare the use of coronary computed tomography angiography (CCTA) between academic and non-academic sites across Europe over the last decade. We analyzed a large multicenter registry (ESCR MR/CT Registry) of stable symptomatic patients who received CCTA 01/2010-01/2020 at 47 (22%) academic and 165 (78%) non-academic sites across 19 European countries. We compared image quality, radiation dose, contrast-media-related adverse events, patient characteristics, CCTA findings, and downstream testing between academic and non-academic sites. Among 64,317 included patients (41% female; 60 ± 13 years), academic sites accounted for most cases in 2010-2014 (52%), while non-academic sites dominated in 2015-2020 (71%). Despite less contemporary technology, non-academic sites maintained low radiation doses (4.76 [2.46-6.85] mSv) with a 30% decline of high-dose scans ( > 7 mSv) over time. Academic and non-academic sites both reported diagnostic image quality in 98% of cases and low rate of scan-related adverse events (0.4%). Academic and non-academic sites examined similar patient populations (41% females both; age: 61 ± 14 vs. 60 ± 12 years; pretest probability for obstructive CAD: low 21% vs. 23%, intermediate 73% vs. 72%, high 6% both, CAD prevalence on CCTA: 40% vs. 41%). Nevertheless, non-academic sites referred more patients to non-invasive ischemia testing (6.5% vs. 4.2%) and invasive coronary angiography/surgery (8.5% vs. 5.6%). Non-academic and academic sites provide safe, high-quality CCTA across Europe, essential to successfully implement the recently updated guidelines for the diagnosis and management of chronic coronary syndromes. However, despite examining similar populations with comparable CAD prevalence, non-academic sites tend to refer more patients to downstream testing. • Smaller non-academic providers increasingly use CCTA to rule out obstructive coronary artery disease. • Non-academic and academic sites provide comparably safe, high-quality CCTA across Europe. • Compared to academic sites, non-academic sites tend to refer more patients to downstream testing.

Clinical Implications and Debates on the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches Trial.

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) was eagerly awaited study in the field of ischemic heart disease. Following the presentation and publication of ISCHEMIA, multiple opinions and viewpoints get complicated. The ongoing debates have been including the relevance of coronary revascularization, noninvasive diagnostic methods, and invasive ischemic testing in patients with stable ischemic heart disease (SIHD). Prior to ISCHEMIA, observational studies indicated the potential of coronary revascularization for improving clinical outcomes, while the randomized Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial did not support the plausible concept. Although the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) 2 trial implied the superiority of percutaneous coronary intervention over medical therapy alone, the clinical relevance of coronary revascularization to improve outcomes and quality of life has been questioned. As a consequence, the ISCHEMIA trial did not demonstrate clear benefits in reducing clinical events but showed antianginal effects of revascularization. This landmark trial also suggested the difficulties of noninvasive ischemia testing rather than computed tomography angiography. Despite the complex results, the ISCHEMIA trial may simplify the clinical indications of coronary revascularization in patients with SIHD. Future publications from the ISCHEMIA trial and debates on the results will sharpen our thinking and understanding.

Additional prognostic value of vasodilator stress CMR in patients with inconclusive stress test to detect coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Guidelines recommend performing a non-invasive testing for ischemia to diagnose coronary artery disease (CAD). However, these tests are frequently inconclusive (25%). This population has been poorly studied because of its heterogeneity. In such cases, stress cardiac magnetic resonance (CMR) may be useful to improve diagnostic certainty. To date, no study has evaluated the prognostic value of stress CMR in these patients presenting with prior inconclusive test. PURPOSE To assess the additional prognostic value of vasodilator stress perfusion CMR in patients with a first inconclusive stress test to detect CAD. METHODS Between 2008 and 2018, consecutive patients with inconclusive stress test prospectively referred for vasodilator stress perfusion CMR with dipyridamole were followed for major adverse cardiovascular events (MACE) defined as cardiac death or myocardial infarction. Inconclusive stress test was defined by echocardiography or nuclear stress testing with uncertain conclusion about the diagnosis of CAD. To characterize this population, an unsupervised clustering analysis was performed using 18 variables. Univariable and multivariable Cox regressions were performed to determine the prognostic value of inducible ischemia by stress CMR in each cluster. RESULTS Of 1502 patients with inconclusive stress test (62 ± 12 years, 59% men), 1441 (96%) completed the CMR protocol and 1397(93%) completed the follow-up (median 5.5 ± 2.3 years). Stress CMR was well tolerated without occurrence of death or severe adverse event. The clustering analysis identified 3 clusters: Cluster 1 (n = 524, 35%) had the highest prevalence of previous percutaneous coronary intervention (PCI), the highest presence of myocardial scar on CMR, the lowest LVEF(35 ± 7%) and the highest degree of LV dilatation. Cluster 2 (n = 406, 27%) had the highest prevalence of previous coronary artery bypass grafting (CABG), preserved LVEF(54 ± 10%), absence of LV dilatation and rate of male(89%). Cluster 3 (n = 572, 38%) had the lowest rate of previous PCI/CABG and of myocardial scar. This cluster gathered the oldest patients (73 ± 11 years), predominantly female (60%), with the highest rate of atrial fibrillation and body mass index. Survival analysis found significant differences across clusters for the occurrence of MACE (p = 0.02). Moreover, inducible ischemia was significantly associated with the occurrence of MACE in each cluster (cluster 1, HR 2.28; [95%CI: 1.31-3.99]; p = 0.0028; cluster 2, HR 3.37; [95%CI, 1.97-5.75]; p < 0.0001; cluster 3, HR 2.73; [95%CI, 1.67-4.46]; p < 0.0001). In multivariable Cox regression, inducible ischemia was an independent predictor of a higher incidence of MACE in each cluster (p < 0.001). CONCLUSIONS Cluster analysis identified 3 different phenotypes of patients with inconclusive stress test that were associated with distinct clinical and prognostic profiles. Within these clusters, CMR stress has an additional prognostic value to predict the occurrence of MACE. Abstract Figure. Kaplan-Meier for MACE in each cluster

Additional prognostic value of vasodilator stress cardiovascular magnetic resonance in patients with inconclusive stress test to detect coronary artery disease

Guidelines recommend performing a non-invasive testing for ischemia to diagnose coronary artery disease (CAD). However, these tests are frequently inconclusive (25%). To assess the additional prognostic value of vasodilator stress perfusion CMR in patients with a first inconclusive stress test to detect CAD. Between 2008 and 2018, consecutive patients with inconclusive stress test to detect CAD prospectively referred for vasodilator stress perfusion CMR with dipyridamole were followed for major adverse cardiovascular events(MACE) defined as cardiac death or myocardial infarction. Inconclusive stress test was defined by stress echocardiography or nuclear stress testing with uncertain conclusion. To characterize this population, an unsupervised clustering analysis of these patients was performed using 18 variables. Univariable and multivariable Cox regressions were performed to determine the prognostic value of inducible ischemia in each of the clusters identified. Of 1502 patients with inconclusive stress test (62 ± 12 years, 59% men), 1397 (93%) completed the follow-up (median 5.5 ± 2.3 years). Stress CMR was well tolerated without severe adverse event. An unsupervised clustering analysis of those patients identified 3 clusters:. – Cluster 1 (n = 524, 35%) had the highest prevalence of previous PCI, the highest presence of a myocardial scar defined by CMR, the lowest LVEF (35 ± 7%) and the highest degree of LV dilatation. – Cluster 2 ( n = 406, 27%) had the highest prevalence of previous CABG (82%), preserved LVEF(54 ± 10%), absence of LV dilatation, and presence of myocardial scar(52%). This cluster comprised predominantly male patients (89%), with the highest rate of dyslipidemia(81%) or hypertension(71%). – Cluster 3 ( n = 572, 38%) had the lowest rate of previous PCI/CABG (9%) and the lowest rate of myocardial scar in CMR(6%). This cluster gathered the oldest patients(73 ± 11 years) and was predominantly female(60%) with the highest rate of atrial fibrillation(51%) or body mass index. Survival analysis found significant differences across clusters for the occurrence of MACE ( P = 0.02). Moreover, the presence of inducible ischemia was significantly associated with the occurrence of MACE in each cluster (cluster 1, hazard ratio HR 2.28; [95% confidence interval CI: 1.31–3.99]; P = 0.0028; cluster 2, HR 3.37; [95%CI, 1.97–5.75]; P < 0.0001; cluster 3, HR 2.73; [95%CI, 1.67–4.46]; P < 0.0001). In a multivariable Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischemia was an independent predictor of a higher incidence of MACE in each cluster ( P < 0.001 for all) ( Fig. 1 ) Cluster analysis of clinical and CMR variables identified 3 different phenotypes with distinct clinical and prognostic profiles. Within these clusters, CMR stress has an additional prognostic value to predict MACE.

Clustering for identification of patients with inconclusive non-invasive testing for ischaemia to detect coronary artery disease

Guidelines recommend performing a non-invasive testing for ischemia to diagnose coronary artery disease (CAD). However, these tests are frequently inconclusive (20–30%) and can lead to uncertainty about the likelihood of CAD. This population has been poorly studied because it is a heterogeneous population difficult to characterise. To characterise a population of patients with inconclusive test using an unsupervised classification algorithm, then to compare the prognosis of each clusters identified. Between 2008 and 2018, consecutive patients with inconclusive stress test to detect CAD prospectively referred for a second stress test were followed for major adverse cardiovascular events (MACE) defined as cardiac death or non-fatal myocardial infarction (MI). Inconclusive stress test was defined by stress echocardiography or nuclear stress testing with uncertain conclusion. Data were analysed by a hierarchical clustering on principal components (HCPC) to perform this unsupervised classification algorithm. Among baseline, clinical and CMR characteristics, 18 variables were used for the clustering of patients. Of 1502 patients with inconclusive stress test (61.9 ± 11.8 years, 59% men), 1397 (93%) completed the follow-up (median 5.5 ± 2.3 years). An unsupervised clustering analysis of those patients identified 3 clusters of phenotypes: cluster 1 ( n = 524, 35%) had the highest prevalence of previous PCI (59%), the highest presence of a myocardial scar defined by CMR (58%), the lowest LVEF (35 ± 7%) and the highest degree of LV dilatation (LVEDVi = 124 ± 25 mL/m 2 ). Cluster 2 ( n = 406, 27%) had the highest prevalence of previous CABG (82%), preserved LVEF (54 ± 10%), absence of LV dilatation (LVEDVi = 82 ± 20 mL/m 2 ), and presence of myocardial scar defined by CMR (52%). This cluster comprised predominantly male patients (89%), with the highest rate of dyslipidemia (81%) or hypertension (71%). Cluster 3 ( n = 572, 38%) had the lowest rate of previous CABG or PCI (9%) and the lowest rate of myocardial scar in CMR (6%). This cluster gathered the oldest patients (73 ± 11 years) and was predominantly female (60%) with the highest rate of atrial fibrillation (51%) or body mass index (31 ± 7.8 kg/m 2 ). Survival analysis found significant differences across clusters for the occurrence of MACE ( P = 0.02) et cardiovascular mortality ( P < 0.0001) ( Fig. 1 ). Using Cox proportional hazards modelling, clusters 1 (hazard ratio: 0.72; 95% confidence interval: 0.50 to 1.04) and 3 (hazard ratio: 0.62; 95% confidence interval: 0.30 to 1.25) had a similar prognostic, which was better than cluster 2 (HR: 1.00 [reference]). Cluster analysis of clinical and CMR variables identified 3 different phenotypes of patients with inconclusive stress test to detect CAD that were associated with distinct clinical and prognostic profiles.

Abstract 13471: Additional Prognostic Value of Vasodilator Stress Cardiovascular Magnetic Resonance in Patients With Inconclusive Stress Test to Detect Coronary Artery Disease

Introduction: Non-invasive testing for ischemia to diagnose coronary artery disease(CAD) are frequently inconclusive(25%). Hypothesis: To assess the prognostic value of stress CMR in patients with a first inconclusive stress test. Methods: Between 2008 and 2018, consecutive patients with inconclusive stress test, defined by stress echocardiography or nuclear testing with uncertain conclusion, prospectively referred for stress CMR with dipyridamole were followed for major adverse cardiovascular events(MACE): cardiac death or myocardial infarction. An unsupervised clustering analysis was performed. Results: Of 1502 patients (62±12yrs, 59%men), 1397 completed the follow-up (median 5.5±2.3yrs). Three clusters were identified: Cluster 1 (n=524) had the highest prevalence of previous PCI, the highest presence of a myocardial scar defined, the lowest LVEF (35±7%) and the highest LV dilatation. Cluster 2 (n=406) had the highest previous CABG prevalence, preserved LVEF, absence of LV dilatation, and presence of myocardial scar. This cluster comprised predominantly male patients, with the highest rate of hypertension. Cluster 3 (n=572) had the lowest rate of previous PCI/CABG, the lowest rate of myocardial scar, predominantly female, the highest atrial fibrillation rate and body mass index. Survival analysis found significant differences across clusters for the occurrence of MACE (p=0.02). Inducible ischemia was associated with MACE occurrence in each cluster (C1, HR 2.28; 95%CI[1.31-3.99]; p=0.0028; C2, HR 3.37; 95%CI[1.97-5.75]; p&lt;0.0001; C3, HR 2.73; 95%CI[1.67-4.46]; p&lt;0.0001). In multivariable analysis, inducible ischemia predicted MACE in each cluster (p&lt;0.001 for all). Conclusions: Cluster analysis identified 3 different phenotypes with distinct clinical and prognostic profiles. Within these clusters, stress CMR has an additional prognostic value to predict MACE..

Early invasive strategy (

The advantages of an early invasive strategy in non-ST-elevation acute coronary syndromes (NSTE-ACS) are well documented. Less clear is the ideal time to perform it (within 24 h, within 72 h, or during hospitalization after positive non-invasive testing for ischemia). In particular, the class IA recommendation for coronary angiography within 24 h in patients with high-risk NSTE-ACS is controversial. Randomized clinical trials and meta-analyses show neutral effects on mortality, while significant positive results are observed only for secondary outcomes (mainly ischemic recurrences). Favorable effects on major cardiovascular events are reported only in the subgroup analysis of a single randomized trial (TIMACS) or in several trials included in the meta-analyses. Thus, these results are far from conclusive and should stimulate new randomized clinical studies to support them. In fact, the logistical implications that this recommendation implies deserve stronger evidence. It is clear that all patients with NSTE-ACS, especially if high-risk, should have the opportunity to undergo a coronary angiogram during hospitalization. However, in the real world, the strict timeline of the international guidelines may be difficult to follow. Therefore, indications that take into account resource availability and the organizational context should be developed. Several regional indications suggest that even in high-risk patients the 24 h time limit for the invasive strategy should not be mandatory, but timing of angiography should be calibrated on clinical presentation and logistical resources, without any a priori automatism.

Additional prognostic value of vasodilator stress CMR in patients with inconclusive stress test to detect coronary artery disease

Abstract Background Guidelines recommend performing a non-invasive testing for ischemia to diagnose coronary artery disease (CAD). However, these tests are frequently inconclusive (25%). This population has been poorly studied because of its heterogeneity. In such cases, stress cardiac magnetic resonance (CMR) may be useful to improve diagnostic certainty. To date, no study has evaluated the prognostic value of stress CMR in these patients presenting with prior inconclusive test. Purpose To assess the additional prognostic value of vasodilator stress perfusion CMR in patients with a first inconclusive stress test to detect CAD. Material Between 2008 and 2018, consecutive patients with inconclusive stress test prospectively referred for vasodilator stress perfusion CMR with dipyridamole were followed for major adverse cardiovascular events (MACE) defined as cardiac death or myocardial infarction. Inconclusive stress test was defined by echocardiography or nuclear stress testing with uncertain conclusion about the diagnosis of CAD. To characterize this population, an unsupervised clustering analysis was performed using 18 variables. Univariable and multivariable Cox regressions were performed to determine the prognostic value of inducible ischemia by stress CMR in each cluster. Results Of 1502 patients with inconclusive stress test (62±12 years, 59% men), 1441 (96%) completed the CMR protocol and 1397 (93%) completed the follow-up (median 5.5±2.3 years). Stress CMR was well tolerated without occurrence of death or severe adverse event. The clustering analysis identified 3 clusters: Cluster 1 (n=524, 35%) had the highest prevalence of previous percutaneous coronary intervention (PCI), the highest presence of myocardial scar on CMR, the lowest LVEF (35±7%) and the highest degree of LV dilatation. Cluster 2 (n=406, 27%) had the highest prevalence of previous coronary artery bypass grafting (CABG), preserved LVEF (54±10%), absence of LV dilatation and rate of male (89%). Cluster 3 (n=572, 38%) had the lowest rate of previous PCI/CABG and of myocardial scar. This cluster gathered the oldest patients (73±11 years), predominantly female (60%), with the highest rate of atrial fibrillation and body mass index. Survival analysis found significant differences across clusters for the occurrence of MACE (p=0.02). Moreover, inducible ischemia was significantly associated with the occurrence of MACE in each cluster (cluster 1, HR 2.28; [95% CI: 1.31–3.99]; p=0.0028; cluster 2, HR 3.37; [95% CI, 1.97–5.75]; p&amp;lt;0.0001; cluster 3, HR 2.73; [95% CI, 1.67–4.46]; p&amp;lt;0.0001). In multivariable Cox regression, inducible ischemia was an independent predictor of a higher incidence of MACE in each cluster (p&amp;lt;0.001). Conclusions Cluster analysis identified 3 different phenotypes of patients with inconclusive stress test that were associated with distinct clinical and prognostic profiles. Within these clusters, CMR stress has an additional prognostic value to predict the occurrence of MACE. Kaplan-Meier for MACE in each cluster Funding Acknowledgement Type of funding source: None

Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus

Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended transseptal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel transconal approach in 7 consecutive patients. A retrospective review was made of a prospectively collected database for consecutive patients undergoing transconal unroofing of transseptal AAOLCA. Surgical repair entails transection of the RVOT, unroofing the septal course of the AAOLCA, followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted. All 7 patients identified were symptomatic. Median age was 48 years (range, 12 to 62). The AAOLCA with transseptal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound and indexed fractional flow reserve, confirming flow-limiting lesion. Importantly, 3 patients had negative provocative noninvasive testing for ischemia. Median postoperative hospital length of stay was 6 days (range, 4 to 12). No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved indexed fractional flow reserve compared with preoperative (0.59 ± 0.16 vs 0.90 ± 0.03, P= .05). Complete unroofing of AAOLCA with transseptal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. Intravascular ultrasound with indexed fractional flow reserve is clinically useful to confirm the hemodynamic significance of specific lesions.

Diabetes Mellitus and Stable Ischemic Heart Disease

More than 30 million Americans have diabetes mellitus (DM), and heart disease is the cause of death in 68% of them. Patients with DM are at increased risk of developing stable ischemic heart disease (SIHD) by several mechanisms. While noninvasive testing for ischemia is an intuitive strategy to reduce cardiovascular events, trial data do not show a clear benefit. For the DM patient with no symptoms and no evidence of SIHD, two randomized trials found no benefit for either nuclear stress or cardiac computed tomography. While silent ischemia is associated with increased cardiovascular risk, on a population level, reducing ischemia does not appear to improve outcomes. Another important consideration in the management of SIHD in DM patients is that recent randomized trial data show no benefit from coronary revascularization for this population. In conclusion, the decision to test for ischemia may be a reasonable option in some DM patient groups; however, in many cases, revascularization for SIHD does not reduce mortality or the rate of myocardial infarction.

Appropriate use of noninvasive ischemia testing to guide revascularization decision making following acute ST elevation myocardial infarction in Latin American countries: Results from an Expert Panel Meeting of the International Atomic Energy Agency

Across Latin American and Caribbean countries (LAC), cardiovascular disease and especially ischemic heart disease is currently the main cause of death both in men and in women. For most LAC, public and community health efforts aim to define care strategies which are both clinically and cost effective and promote primary and secondary prevention, resulting in improved patient outcomes. The optimal approach to deal with acute events such as ST-elevation myocardial infarction (STEMI) is a matter of controversy; however, there is an expanding role for assessing residual ischemic burden in STEMI patients following primary percutaneous coronary intervention (PPCI). Although randomized clinical trials have established the value of staged fractional flow reserve (FFR)-guided revascularization, the use of noninvasive functional imaging modalities may play a similar role at a much lower cost. For LAC, available stress imaging techniques could be applied to define residual ischemia in the non-infarct related artery and to target revascularization in a staged procedure after PPCI. The use of nuclear cardiac imaging, supported by its relatively wide availability, moderate cost, and robust quantitative capabilities, may serve to guide effective care and to reduce subsequent cardiac events in patients with coronary artery disease. This noninvasive approach may avert potential safety issues with repeat and lengthy invasive procedures, and serve as a baseline for subsequent follow-up stress testing following the index STEMI event. This consensus document was devised from an Expert Panel Meeting of the International Atomic Energy Agency (IAEA), highlighting available evidence with a focus on the utility of stress myocardial perfusion imaging in post-STEMI patients. The document could serve as guidance to the prudent and appropriate use of nuclear imaging for targeting therapeutic management and avoiding unnecessary invasive procedures within LAC, where resources could be scarce.

Power of Contemporary Clinical Strategies to Detect Patients with Obstructive Coronary Artery Disease

Background: Non-invasive Ischemia Testing (NIST) is recommended for most patients suspected to have stable coronary artery disease (CAD) before invasive cardiac angiography (ICA). We sought to assess the diagnostic predictive ability of NIST over clinical risk profiling in a contemporary sample of patients undergoing the currently recommended diagnostic triage strategy. Methods and results: From 2006 - 2011, 2600 consecutive patients without known CAD undergoing elective ICA in a single tertiary - care centre were retrospectively identified and the prevalence of obstructive CAD determined. To understand the incremental value of frequently used clinical parameters in predicting obstructive CAD, receiver - operating - characteristic curves were plotted for six sequential models starting with Framingham risk score and then progressively adding multiple clinical factors and finally NIST results. At ICA 1268 patients (48.8%) had obstructive. The vast majority (85%) were classified in an intermediate clinical pre - test probability of CAD and NIST prior to ICA was used in 86% of the cohort. The most powerful correlate of obstructive CAD was the presence of severe angina (OR = 9.1, 95% confidence interval (CI), 4.3 - 19.1). Accordingly, the incorporation of NIST in a sequential model had no significant effect on the predictive ability over that achieved by clinical and symptomatic status model (C - statistic 0.754; 95% CI, 0.732 - 0.776, p = 0.28). Conclusions: Less than half the patients with suspect stable obstructive CAD referred to a tertiary level centre for elective ICA had the diagnosis confirmed. In this clinical setting, the results of NIST may not have the power to change the discriminative ability over clinical judgment alone.

Avoiding Unnecessary Coronary Angiographic Studies but Getting the Balance Right

The occurrence of typical angina pectoris in individuals without obstructive coronary artery disease is common, as attested by results of large studies. (1) Although most guidelines for triaging patients for cardiac catheterization recommend risk assessment and noninvasive testing, some guidelines recommend proceeding directly to coronary arteriography in specific patient subgroups. The aim of avoiding unnecessary invasive investigations is laudable, as it should reduce both risk and costs associated with the procedure. Of interest, Patel et al (1) carried out a study in 398,978 patients (median age 61 years; 53% men) without known coronary artery disease (CAD) who were undergoing elective catheterization. The patients’ clinical characteristics, conventional risk factors (26.0% had diabetes, and 70% had hypertension), angina symptoms and the results of noninvasive diagnostic testing were correlated with the presence of obstructive CAD (>70% diameter reduction). Noninvasive testing was performed in 84% of the patients. Of importance, angiography showed that only 37.6% of patients had obstructive CAD and almost 40% of patients had no CAD (defined as < 20% stenosis in all vessels). As expected, independent predictors of obstructive CAD were male sex, older age, insulin-dependent diabetes and dyslipidemia. Very interestingly, patients with a positive result on a noninvasive test –indicative of myocardial ischemiawere only moderately more likely to have CAD than those who did not undergo any testing.Thus in the Patel study (1) only a little more than one third of patients without known disease who underwent elective cardiac catheterization had obstructive CAD, but most of them had angina and a positive result of non-invasive testing for ischemia. In this issue of the Journal, Kevorkian et al. (2) analyzed consecutive diagnostic coronary angiographies for suspected CAD in 12,686 admitted patients in five

Sténose critique du tronc commun gauche asymptomatique : quand les tests non invasifs d’ischémie sont faussement rassurants

Left main coronary artery severe stenosis is frequently very symptomatic and is considered as a classical contraindication for non-invasive ischemia testing. When performed, those tests usually yield a large area of ischemia associated with a rich symptomatology. We report the case of a 69-year-old completely asymptomatic man in whom both treadmill effort testing and dobutamine stress echocardiography were falsely reassuring as they eliminated significant ischemia despite the presence of a critical stenosis of distal left main artery ultimately confirmed by angiography. Dobutamine 2D strain performed afterwards was pathological and could have corrected the initially reassuring diagnosis.

Outcomes of patients presenting with acute coronary syndromes and negative Troponin-T

The aim of the study was to compare need for revascularization and clinical course between troponin-positive and troponin-negative patients with unstable angina pectoris defined as class IIIB according to Braunwald classification. Methods: The study group consisting of 104 patients was divided into troponin-positive (28 patients) and troponin-negative (76 patients) subgroups. Per study design all patients underwent coronary angiography. The subgroups were compared in regard to angiographic status and consequently the need for revascularization. Additionally, major adverse cardiac events (MACE) consisting of death, myocardial infarction, in-hospital revascularization during 30-days follow-up were assessed in subgroups. Results: In 58 (76%) patients with negative troponin test, the angiographically significant coronary artery stenosis was shown. Major adverse cardiac events were similar in both groups. Regardless of the initial TnT status, in both groups revascularizations (percutaneous or surgical) were performed with high frequency (89 versus 72%, P=NS). Conclusion: In patients with unstable angina in class IIIB according to Braunwald classification, the negative cardiac troponin test did not exclude severe coronary artery disease, which in the majority of patients required revascularization without any additional non-invasive testing for ischemia. Therefore, we postulate that patients with clinically evident unstable angina (IIIB) should be referred to early invasive assessment despite negative troponin T screening.

Association of patients’ perception of health status and exercise electrocardiogram, myocardial perfusion imaging, and ventricular function measures

Background Patients’ viewpoint of their health status is increasingly used as an important outcome measure of the success of treatments. Because clinicians rarely formally measure patients’ health-related quality of life, the question arises whether noninvasive testing for ischemia can provide similar information regarding physical functioning and general health perception. Methods We measured physical functioning and general health status with the Medical Outcomes Study Short Form (SF-36) survey in 195 consecutive patients (68% male, mean age 55.6 ± 11.1 years) referred for exercise testing with myocardial perfusion imaging. The survey was completed immediately before the exercise test. Results In the multivariate analysis, the strongest predictor of physical functioning and general health perception was metabolic equivalents. However, the best model, including demographic, clinical, and test variables, predicted only 14% of the variation in physical functioning and 10% of the variability in general health perception. Conclusions The variation in physical functioning and general health perception, as measured by the SF-36, among patients referred for exercise testing is not predicted well by the results of the test. As expected, several test results are significantly associated with physical functioning and general health perception; however, there was substantial overlap among individual patients, suggesting that the parameters are poor surrogates for the actual assessment of the domains. If these domains are deemed important to tracking patient outcomes, then they should supplement the current assessments of these patients. (Am Heart J 2000;140:409-18.)