Prevalence Of Significant Coronary Artery Disease Research Articles

Stress Perfusion Cardiac Magnetic Resonance vs SPECT Imaging for Detection of Coronary Artery Disease

BackgroundGadaCAD2 was 1 of 2 international, multicenter, prospective, Phase 3 clinical trials that led to U.S. Food and Drug Administration approval of gadobutrol to assess myocardial perfusion and late gadolinium enhancement (LGE) in adults with known or suspected coronary artery disease (CAD). ObjectivesA prespecified secondary objective was to determine if stress perfusion cardiovascular magnetic resonance (CMR) was noninferior to single-photon emission computed tomography (SPECT) for detecting significant CAD and for excluding significant CAD. MethodsParticipants with known or suspected CAD underwent a research rest and stress perfusion CMR that was compared with a gated SPECT performed using standard clinical protocols. For CMR, adenosine or regadenoson served as vasodilators. The total dose of gadobutrol was 0.1 mmol/kg body weight. The standard of reference was a 70% stenosis defined by quantitative coronary angiography (QCA). A negative coronary computed tomography angiography could exclude CAD. Analysis was per patient. CMR, SPECT, and QCA were evaluated by independent central core lab readers blinded to clinical information. ResultsParticipants were predominantly male (61.4% male; mean age 58.9 ± 10.2 years) and were recruited from the United States (75.0%), Australia (14.7%), Singapore (5.7%), and Canada (4.6%). The prevalence of significant CAD was 24.5% (n = 72 of 294). Stress perfusion CMR was statistically superior to gated SPECT for specificity (P = 0.002), area under the receiver operating characteristic curve (P < 0.001), accuracy (P = 0.003), positive predictive value (P < 0.001), and negative predictive value (P = 0.041). The sensitivity of CMR for a 70% QCA stenosis was noninferior and nonsuperior to gated SPECT. ConclusionsVasodilator stress perfusion CMR, as performed with gadobutrol 0.1 mmol/kg body weight, had superior diagnostic accuracy for diagnosis and exclusion of significant CAD vs gated SPECT.

Temporal trends and outcomes of patients with chronic limb-threatening ischemia with and without history of coronary artery disease: insights from the us national inpatient sample database.

The burden and prognostic significance of coronary artery disease (CAD) in adults with peripheral artery disease and chronic limb-threatening ischemia (CLTI) is unknown. Temporal trends in prevalence of significant CAD (history of myocardial infarction or coronary revascularizations) in hospitalizations for CLTI were determined using the 2000 to 2018 National Inpatient Sample (NIS) database. A multivariable regression analysis of outcomes was performed based on presence or absence of CAD. Among 13 575 099 hospitalizations for CLTI (41% female, 69% white, mean age 69 years), 23% had concomitant CAD, of which 11% underwent lower extremity arterial revascularization (43.6% endovascular and 56.4% surgical). The prevalence of concomitant CAD with CLTI increased from 15.3% in 2000 to 23.1% in 2018. Furthermore, the frequency of endovascular revascularization in adults with CAD and CLTI increased from 15.1% to 48.3%, while there was a decreasing trend of surgical revascularization, from 84.9% to 51.7%. After multivariate adjustments, CLTI with CAD was associated with increased risk of in-hospital mortality (OR, 1.40; 95% CI, 1.32-1.47; P less than .0001) and bleeding requiring transfusion (OR, 1.10; 95% CI, 1.06-1.12; P less than .0001) compared with patients with CLTI without CAD. As compared with surgical revascularization, endovascular revascularization was associated with lower risk of in-hospital mortality in both patients with CLTI with CAD (OR, 0.69; 95% CI, 0.63-0.76; P less than .001) and CLTI without CAD (OR, 0.71; 95% CI, 0.67-0.76; P less than .001). Prevalence of CAD has increased in adults presenting with CLTI and is associated with poor outcomes, warranting the need for effective interventions and secondary prevention in this high-risk population.

Prediction of significant coronary artery disease in acute chest pain without infarction in emergency department: MAPAC Cardio-PreTest model.

Acute nontraumatic chest pain is a frequent reaso n for consultation in emergency departments and represents a diagnostic challenge. The objective is to estimate the risk of significant coronary artery disease (CAD) in patients with cardiogenic acute chest pain for whom the diagnosis of infarction was ruled out in the emergency department with a nondiagnostic ECG and negative high-sensitivity troponins. We prospectively recruited 1625 patients from emergency departments of seven Spanish hospitals. The outcome was presence of significant CAD determined by presence of ischaemia in functional tests or more than 70% stenosis in imaging tests. In this study, we developed a predictive model and evaluated its performance and clinical utility. The prevalence of significant CAD was 14% [227/1625; 95% confidence interval (CI), 12-16]. MAPAC Cardio-PreTest model included seven predictors: age, sex, smoking, history of hypertension, family history of CAD, history of hyperuricaemia, and type of chest pain. The optimism-adjusted model discrimination was C-statistic 0.654 (95% CI, 0.618-0.693). Calibration plot showed good agreement between the predicted and observed risks, and calibration slope was 0.880 (95% CI, 0.731-1.108) and calibration-in-the-large -0.001 (95% CI, -0.141 to 0.132). The model increased net benefit and improved risk classification over the recommended approach by the European Society of Cardiology [Net Reclassification Index (NRI) of events = 5.3%, NRI of nonevents = 7.0%]. MAPAC Cardio-PreTest model is an online prediction tool to estimate the individualised probability of significant CAD in patients with acute chest pain without a diagnosis of infarction in emergency department. The model was more useful than the current alternatives in helping patients and clinicians make individually tailored choices about the intensity of monitoring or additional coronary tests.

Relationship between sexual differences and cardiovascular risk factors in the prevalence of asymptomatic coronary disease

BackgroundThis study investigated the sexual differences of coronary artery disease (CAD) prevalence and its association with cardiovascular risk factors in the asymptomatic population. MethodsIn total 6434 asymptomatic participants without known CAD (1740 women and 4694 men) underwent coronary computed tomography angiography (CCTA). The prevalence of significant CAD (diameter stenosis ≥50%) and other CCTA findings were compared by sex, and its influence on CAD was investigated in groups stratified by the number of cardiovascular risk factors, including age (>55 years), hypertension, diabetes, dyslipidemia, and current smoking. ResultsThe prevalence of current smokers, hypertension, and diabetes were higher in men than women. The mean coronary artery calcium score was 13.1 ± 58.4 for women and 51.1 ± 158.2 for men; the coronary atherosclerosis burden indices were significantly higher in men than women. Significant CAD was identified in 65 women (3.7%) and 429 men (9.1%), showing a significant association (adjusted odds ratio [OR] 2.38, P < 0.001). The relatively higher risk for significant CAD in men was observed in patients with fewer risk factors, and the risk difference was not significant in patients with many risk factors (adjusted ORs: 7.69, 3.37, 1.71, 1.31, and 0.88 in patients with 0, 1, 2, 3, and 4–5 risk factors, respectively). The association between sex and risk factor groups was significant (P < 0.001). ConclusionsIn the asymptomatic population, a significantly higher CAD prevalence was noted in men than women. However, women with a high number of cardiovascular risk factors showed a CAD prevalence similar to that of men.

Evaluating value of positive T wave in lead V1 and TV1 > TV6 pattern in predicting significant coronary artery disease in patients undergoing coronary angiography.

BACKGROUNDThe aim of this study was to predict significant coronary artery disease (CAD) in patients undergoing coronary angiography.METHODSIn this cross-sectional study, data of 384 patients who underwent angiography during 2015-2017 were reviewed. Electrocardiograms (ECGs) were evaluated in terms of having positive T wave in lead V1 (TV1) described as T wave with amplitude of more than 0.15 mV and angiography records were assessed for presence of significant CAD defined as presence of ≥ 70% internal diameter stenosis in at least one major epicardial coronary artery or more than 50% stenosis in left main artery (LMA).RESULTSOut of 384 patients who participated in this study with mean age of 63.6 ± 10.2 years (40-89 years), 71.6% showed positive TV1 and significant CAD simultaneously and left anterior descending artery (LAD) and left circumflex artery (LCX) lesions were more frequently reported in coronary angiography. Based on chi-square test, the prevalence of significant CAD was obviously more in those with positive TV1 as compared to those without this finding [odds ratio (OR) = 2.74, 95% confidence interval (CI): 1.80-4.19, P < 0.001]. Mann-Whitney test showed significant difference in number of coronary arteries involved in CAD between presence of positive and negative T wave in lead V1 (P < 0.001). Great number of patients with significant CAD had remarkably higher T wave amplitude in lead V1 in comparison to lead V6 (OR = 6.22, 95% CI: 3.14-12.30, P < 0.001).CONCLUSIONPositive TV1 and TV1 > TV6 pattern can be considered as a predictor for significant CAD in patients with otherwise normal ECG.

Evaluation of Routine Coronary Angiography Before Pulmonary Thromboendarterectomy

At the University of California, San Diego, routine coronary angiography has generally been performed in men 40 years of age and older and women 45 years of age and older before pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (CTEPH). The prevalence of significant coronary artery disease (CAD) in this population has not been evaluated, however, and the optimal screening strategy has not been established. This study sought to evaluate whether the current approach may be better optimized on the basis of cardiac risk factors. This study included 462 consecutive patients with CTEPH who were undergoing preoperative coronary angiography for pulmonary thromboendarterectomy. Baseline demographic and medical information was recorded. Major cardiac risk factors included: diabetes, hypertension, hyperlipidemia, body mass index 25 kg/m2 or greater, tobacco use, and family history of CAD. Charts were then reviewed for presence of significant CAD and revascularization. Significant CAD was found in 13.4% of patients who underwent routine preoperative coronary angiography; it was present in only 5% of patients younger than 50 years of age, compared with 16% of patients 50 years old and older. No patient younger than 50 years of age without cardiac risk factors was found to have significant CAD. Furthermore, in patients younger than 50 years of age, significant CAD was found only among those with 3 or more major risk factors. In patients younger than 50 years of age with CTEPH, the prevalence of significant CAD was low. Omitting preoperative coronary angiography in this subset of patients is reasonable when no coronary risk factors are present. Preoperative coronary angiography is warranted in individuals 50 years of age and older, as well as in those younger than 50 years who have significant risk factors for CAD.

P1552 Dobutamine stress echocardiography as a screening tool for coronary artery disease detection in patients with end-stage liver disease awaiting transplantation

Abstract Indroduction The prevalence of coronary artery disease (CAD) in patients with end-stage liver disease (ESLD) is unknown. However, patients with CAD and ESLD are at increased perioperative risk during liver transplantation. Currently there is no standard protocol for CAD screening in patients with ESLD awaiting orthotopic liver transplantation. We present preliminary data of our experience with dobutamine stress echocardiography in those patients. Methods Fifty patients (26 males, mean age of 59 years) with end-stage liver disease awaiting transplantation and no history of CAD underwent dobutamine stress echo. The etiology of their hepatic disease was hepatitis B (6 patients), hepatitis C (6 patients), primary billiary cirrhosis (10 patients), sclerosing cholangitis (8 patients), alcoholic hepatitis (10 patients) and polycystic disease (2 patients), while 8 patients had end-stage liver disease of unknown etiology. Twenty-six patients had risk factors for CAD. Eighteen patients had one risk factor and only 8 patients had 2 risk CAD factors. All patients received dobutamine infusion (at escalating doses of 5, 10, 20, 30 and 40 μgr/kg/min), targeting a 85% or more of their age-predicted maximum heart rate. Atropine was administered in 6 patients. Results All 50 patients had normal inotropic response of left ventricle, without evidence of ischemia (100% studies were negative for ischaemia). No patient had major intolerance to dobutamine. Eight patients experienced hypotension responded to infusion of normal saline. One patient developed paroxysmal supraventricular tachycardia, which was treated with intravenous bolus of adenosine. No patient had cardiovascular events during a follow-up ranging from 1 to 18 months. Twelve patients underwent liver transplantation without any periprocedural cardiovascular events. Conclusions Dobutamine stress echocardiography is a safe and reliable method for CAD screening in the labile patients with ESLD who are candidates for orthotopic liver transplantation. It seems that the prevalence of significant CAD in this high-risk population is low.

Association of coronary artery disease and peripheral arterial disease in patients undergoing elective open abdominal aortic aneurysm repair

Introduction: Open surgical repair of abdominal aortic aneurysm (AAA) is one of the commonest aortic surgeries performed in tertiary care vascular centres. As association of coronary artery disease (CAD) and peripheral arterial disease (PAD) is high in these patients, need for cardiac risk stratification with or without coronary intervention prior to surgery and its effect on long term survival benefit have been debated. In our institution, all patients who undergo elective aortic aneurysm surgery undergo diagnostic coronary angiogram. Intervention (Percutaneous Coronary Intervention or coronary artery bypass surgery) was performed prior to surgery, if patient was symptomatic/ had multiple critical occlusions in coronary vessels. We also looked into the prevalence of peripheral arterial disease in these patients. Methods: Single centre retrospective study. 199 patients who underwent elective aortic aneurysm repair in the last 10 years were studied. Data was collected from electronic and hospital medical records and analysed. Results: Significant CAD was seen in 105 patients (52.7%) out of which 40 patients (20.1%) underwent preoperative intervention while 65 patients (32.7%) underwent surgery without the same. Prevalence of significant CAD in AAA was high (52.7%) whereas PAD was seen in 26 patients (13.1%). Conclusion: We suggest it worthwhile to assess the coronary status in these patients preoperatively for risk stratification. Prophylactic coronary revascularization should be individualized and can prevent post-operative adverse cardiac events. Medical treatment for concomitant CAD with no obvious inducible ischemia does not confer unfavorable outcomes. Presence of PAD should not be overlooked and should be identified and intervened in the same setting if critical to decrease the morbidity.

Elevated high-sensitivity troponin does not indicate the presence of coronary artery disease in patients presenting with supraventricular tachycardia.

Patients with supraventricular tachycardia (SVT) and patients with coronary artery disease (CAD) often present with similar symptoms (chest pain, shortness of breath), similar electrocar¬diographic changes and elevated high-sensitivity troponin (Tn). It is not clear whether troponin reflects critical CAD or is elevated due to other causes in patients presenting with SVT. The aim of this study was to assess the role of elevated troponin in patients presenting with SVT. Patients undergoing radiofrequency ablation (RFA) for SVT and simultaneous coronary an¬giography at the Heart Centre Lucerne, Switzerland between January 2010 and October 2014 were in¬cluded in this analysis. Significant CAD was defined as diameter-stenosis ≥ 75% in vessels > 2.0 mm. The level of Tn was compared between patients with the presence or absence of CAD on coronary angi¬ography. A Tn value of ≥ 0.014 μg/L was considered as elevated. During the study period a total of 473 patients underwent RFA for SVT. The study population consisted of 326 patients (69%, mean age 60 ± 12 years) who underwent invasive coronary angiogra¬phy during the same session. The prevalence of significant CAD was 14% (45/326 patients). The highest prevalence of CAD was found in patients with atrial flutter (35%, 18/45 patients). Tn was elevated in 83% (10/12 patients) with significant CAD and in 47% (26/55 patients) without CAD. The prevalence of CAD is low in patients with SVT, which questions the role of routine invasive coronary angiography during RFA. Tn measurement did not reliably exclude or confirm CAD in these patients.

Abstract 14772: Routine Coronary Angiography Prior to Pulmonary Thromboendarterectomy in Patients With Chronic Thromboembolic Pulmonary Hypertension

Introduction: At UC San Diego Health System, routine coronary angiography has been performed in men &gt;40 years and women &gt;45 years (or earlier in those with significant cardiovascular risk factors) prior to pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH). However, the prevalence of significant coronary artery disease (CAD) in this population has not been evaluated, and the optimal screening strategy has not been systematically established. Hypothesis: We hypothesized that the current approach of routine age-based coronary angiography in screening candidates for PTE may be better optimized based on cardiac risk factors. Methods: The study included 349 consecutive patients (51.3% male) with CTEPH undergoing preoperative coronary angiography for PTE between January 1, 2007 and November 7, 2014. Charts were reviewed for baseline demographic and medical information. Major cardiac risk factors included: diabetes, hypertension, hyperlipidemia, obesity (BMI ≥25 kg/m2), tobacco use, and family history of CAD. Coronary angiography reports and PTE operative reports were reviewed for significant CAD (≥50% obstruction) and revascularization. Results: Significant CAD was found in 43 (12.3%) of the 349 patients who underwent routine preoperative coronary angiography. The subset with significant CAD included 14 (8.2%) of 170 women and 29 (16.2%) of 179 men. Significant CAD was present in only 5.6% of patients ≤50 years of age, compared to 14.6% of patients &gt;50 years of age. The absence of major cardiac risk factors was a key indicator in excluding significant CAD in patients ≤50 years: no patient ≤50 years without risk factors for CAD was found to have significant coronary artery obstruction. Furthermore, in patients ≤50 years, significant CAD was found only among those with ≥3 major risk factors. Conclusions: In patients ≤50 years with CTEPH, the prevalence of significant CAD was low, and omitting preoperative coronary angiography in this subset of men and women may be reasonable when no cardiac risk factors are present. Routine preoperative coronary angiography is reasonable in individuals &gt;50 years, as well as those ≤50 years with significant risk factors or clinical suspicion of CAD.

Diagnostic Accuracy of Electrocardiographic ST-Segment Depression in Patients With Rapid Atrial Fibrillation for the Prediction of Coronary Artery Disease

BackgroundWe aimed to examine the diagnostic value of ST-segment depression in patients with rapid atrial fibrillation (AF) for the prediction of coronary artery disease (CAD). MethodsHemodynamically stable patients with AF, and a heart rate > 80% of their maximum predicted according to their age, were allocated to 2 groups according to their electrocardiographic findings on admission: group A included patients without any ST-segment abnormalities and group B, patients with downward or horizontal ST-segment depression ≥ 1 mm in 2 or more contiguous leads. Group A patients were subjected to a dobutamine stress echo or Tl-201 myocardial single-photon emission computed tomography, followed by coronary angiography in case of abnormal results and Group B patients to coronary angiography. CAD was defined angiographically as stenosis of ≥ 50% in any major epicardial coronary vessel. ResultsOut of 115 consecutive patients, with a mean age of 65.9 ± 10.2 years, 42.6% were male, 18.3% smokers, 68.7% hypertensive, 21.7% had diabetes, and 40% had hyperlipidemia. We enrolled 71 and 44 patients in group A and B, respectively. Prevalence of significant CAD among studied patients was 21.7%, 3/71 (4.2%) and 22/44 (50.0%) in group A and B, respectively. Overall ST-segment depression during rapid AF had 88.0% sensitivity (95% confidence interval [CI], 67.7%-96.8%) and 75.6% specificity (95% CI, 65.2%-83.7%) in predicting presence of CAD, and positive and negative predictive value was 50.0% (95% CI, 34.8%-65.2%) and 95.8% (95% CI, 87.3%-98.7%), respectively. ConclusionsIn consecutive patients with rapid AF, the absence of ST-segment depression might indicate absence of CAD.

Prevalence and extent of atherosclerotic coronary artery disease and related outcome based on coronary computed tomographic angiography in asymptomatic elderly patients: retrospective cohort study

There is little data regarding coronary artery disease (CAD) and/or atherosclerotic plaques on coronary computed tomographic angiography (CCTA) among the elderly and its outcome, especially in asymptomatic patients. Using CCTA, we evaluated the prevalence and extent of CAD and/or atherosclerosis and related outcomes in asymptomatic elderly patients as compared with symptomatic elderly patients. The study included 1,196 consecutive patients aged 70 years or older who underwent CCTA over a 2-year period. Data were retrospectively evaluated for clinical cardiovascular risk factors with co-morbidities, and CCTA findings, including calcium scores, atherosclerotic plaques (number, plaque-segment score, plaque-extent score, and plaque-significant score) and presence of significant CAD. Follow-up data for active management and all-cause mortality after CCTA were collected for 2 years. Two-sided Student's t test for independent samples, Chi square contingency tables, and Kaplan-Meier survival curves were used for statistical analysis. Data for 454 asymptomatic and 742 symptomatic elderly patients were analyzed. The prevalence of significant CAD and the extent of atherosclerotic plaques did not differ between the two groups (all P > 0.05). Asymptomatic patients with significant CAD on CCTA, were less likely to receive active management (P < 0.001), which may be related to the higher death rate in this group (P = 0.012) than in the symptomatic patients with significant CAD. Overall, symptoms were not related to the presence of significant CAD or to the extent of atherosclerosis in these elderly patients. However, all-cause mortality was higher in the asymptomatic patients with significant CAD than in the symptomatic ones.

Prevalence of Severe Subclinical Coronary Artery Disease on Cardiac CT and MRI in Patients with Extra-cardiac Arterial Disease

Patients with extra-cardiac arterial disease (ECAD) are at high risk of coronary artery disease (CAD). Prevalence of silent, significant CAD in patients with stenotic or aneurysmal ECAD was examined. Early detection and treatment may reduce CAD mortality in this high-risk group. ECAD patients without cardiac complaints underwent computed tomography (CT) for calcium scoring, coronary CT angiography (cCTA) if calcium score was 1,000 or under, and adenosine perfusion magnetic resonance imaging (APMR) if there was no left main stenosis. Significant CAD was defined as calcium score over 1000, cCTA-detected coronary stenosis of at least 50% lumen diameter, and/or APMR-detected inducible myocardial ischemia. In cases of left main stenosis (or equivalent) or myocardial ischemia, patients were referred to a cardiologist. The prevalence of significant CAD was 56.8% (95% CI 47.5 to 66.0). One-hundred and eleven patients were included. Eighty-four patients (76%) had stenotic ECAD, and 27 (24%) had aneurysmal disease. In patients with stenotic ECAD, significant coronary stenosis was present in 32 (38%) and inducible ischemia in eight (12%). Corresponding results in aneurysmal ECAD were eight (30%) and two (11%), respectively (P for difference >.05). Sixteen (19%) patients with stenotic and six (22%) with aneurysmal ECAD were referred to a cardiologist, with subsequent cardiac intervention in seven (44%) and three (50%), respectively (both P >.05). Patients with stenotic or aneurysmal ECAD have a high prevalence of silent, significant CAD.

Prevalence of Severe Subclinical Coronary Artery Disease on Cardiac CT and MRI in Patients with Extra-cardiac Arterial Disease

Patients with extra-cardiac arterial disease (ECAD) are at high risk of coronary artery disease (CAD). Prevalence of silent, significant CAD in patients with stenotic or aneurysmal ECAD was examined. Early detection and treatment may reduce CAD mortality in this high-risk group. ECAD patients without cardiac complaints underwent computed tomography (CT) for calcium scoring, coronary CT angiography (cCTA) if calcium score was 1,000 or under, and adenosine perfusion magnetic resonance imaging (APMR) if there was no left main stenosis. Significant CAD was defined as calcium score over 1,000, cCTA-detected coronary stenosis of at least 50% lumen diameter, and/or APMR-detected inducible myocardial ischemia. In cases of left main stenosis (or equivalent) or myocardial ischemia, patients were referred to a cardiologist. The prevalence of significant CAD was 56.8% (95% CI 47.5 to 66.0). One-hundred and eleven patients were included. Eighty-four patients (76%) had stenotic ECAD, and 27 (24%) had aneurysmal disease. In patients with stenotic ECAD, significant coronary stenosis was present in 32 (38%) and inducible ischemia in eight (12%). Corresponding results in aneurysmal ECAD were eight (30%) and two (11%), respectively (p for difference >.05). Sixteen (19%) patients with stenotic and six (22%) with aneurysmal ECAD were referred to a cardiologist, with subsequent cardiac intervention in seven (44%) and three (50%), respectively (both p >.05). Patients with stenotic or aneurysmal ECAD have a high prevalence of silent, significant CAD.

Screening for coronary artery disease after mediastinal irradiation in Hodgkin lymphoma survivors.

8568 Background: Cardiovascular diseases are the most common non-malignant cause of death in Hodgkin Lymphoma (HL) survivors, especially those who had mediastinal irradiation as part of their treatment. We investigated the role of CT coronary angiography (CTA) as a screening tool for coronary artery disease (CAD) in asymptomatic HL survivors, related findings to stress testing and subsequent interventions. We also evaluated acceptance of screening. Methods: Patients were eligible if at least 10 years disease-free and treated with mediastinal radiotherapy. All patients were screened with ECG, stress testing and CTA. Primary endpoint was significant CAD (stenosis &gt;50%) on CTA. A sample size of 50 patients would achieve ≥80% power to detect a difference of 13% (≥20% vs a population proportion of 7%) using a two-sided binominal test. Allowing for non-evaluable and false-positive scans, we considered CTA screening to be indicated for testing in a larger population if in ≥six patients revascularization would be necessary. Results: Fifty-two patients were included, 48 patients underwent CTA. Median age was 47 years, time since HL diagnosis 21 years. Most patients had no risk factors for CAD. There were 45 evaluable scans. Prevalence of significant CAD on CTA was found in 20% (N=9), and significantly increased compared to the 7% expected abnormalities (p=0.01, 95% CI 8.3-31.7%). In 5 of the 8 patients who underwent conventional angiography, significant CAD was confirmed, and revascularization performed. Two patients were started on medication. Stress testing was inaccurate for determining CAD: all participants were asymptomatic and 1 patient with significant CAD had signs of ischemia. Ninety percent of the participants were content with the screening offered in this study, regardless whether the CTA showed abnormalities or not. Conclusions: Prevalence of significant CAD among HL survivors is high. In our participants even the most severe and life-threatening CAD was not preceded by typical symptoms. In symptomatic cardiac patients revascularization improves survival. This might justify both screening by CTA and intervention in this asymptomatic population, but needs to be further evaluated in a larger cohort. Clinical trial information: NCT01271127.

Diagnostic Performance of Computed Tomography Coronary Angiography (from the Prospective National Multicenter Multivendor EVASCAN Study)

Computed tomographic coronary angiography (CTCA) has been proposed as a noninvasive test for significant coronary artery disease (CAD), but only limited data are available from prospective multicenter trials. The goal of this study was to establish the diagnostic accuracy of CTCA compared to coronary angiography (CA) in a large population of symptomatic patients with clinical indications for coronary imaging. This national, multicenter study was designed to prospectively evaluate stable patients able to undergo CTCA followed by conventional CA. Data from CTCA and CA were analyzed in a blinded fashion at central core laboratories. The main outcome was the evaluation of patient-, vessel-, and segment-based diagnostic performance of CTCA to detect or rule out significant CAD (≥50% luminal diameter reduction). Of 757 patients enrolled, 746 (mean age 61 ± 12 years, 71% men) were analyzed. They underwent CTCA followed by CA 1.7 ± 0.8 days later using a 64-detector scanner. The prevalence of significant CAD in native coronary vessels by CA was 54%. The rate of nonassessable segments by CTCA was 6%. In a patient-based analysis, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of CTCA were 91%, 50%, 68%, 83%, 1.82, and 0.18, respectively. The strongest predictors of false-negative results on CTCA were high estimated pretest probability of CAD (odds ratio [OR] 1.97, p <0.001), male gender (OR 1.5, p<0.002), diabetes (OR 1.5, p <0.0001), and age (OR 1.2, p <0.0001). In conclusion, in this large multicenter study, CTCA identified significant CAD with high sensitivity. However, in routine clinical practice, each patient should be individually evaluated, and the pretest probability of obstructive CAD should be taken into account when deciding which method, CTCA or CA, to use to diagnose its presence and severity.

ST-segment depression during vasodilator stress is of minor clinical importance in women with normal myocardial perfusion imaging and low or intermediate risk of coronary artery disease

The prognostic value of electrocardiographic (ECG) ST-segment depression during vasodilator stress testing in patients with normal myocardial perfusion scintigraphy (MPS) is based on retrospective studies with controversial results. Moreover, the true incidence of obstructive coronary artery disease (CAD) in these patients is unknown. During a 33-month period, all consecutive patients referred for MPS were prospectively evaluated for interpretable ST-segment depression ≥ 1 mm during vasodilator stress testing. Of 1,687 patients with normal MPS and without known CAD, 109 (100 women) aged 65.2 ± 9.2 years demonstrated ST-segment shifts and formed the ECG-positive group. The pretest probability of CAD was low in 56%, intermediate in 39% and high in 5%. They were advised to proceed to coronary angiography. An equal number of patients with normal MPS and no ECG abnormalities matched for CAD predisposing factors comprised the control group. Follow-up of both groups was accomplished through a telephone interview. Fifty-two patients from the ECG-positive group (48%) consented to coronary angiography. Six (11.5%) had obstructive CAD (≥50% lumen stenosis), one with left main artery disease, while three required revascularization. Follow-up was complete in 99 ECG-positive patients for a period of 20.6 ± 8.9 months. One hard event (non-fatal myocardial infarction) and one soft event (revascularization) were observed. No event was recorded in the control group. In patients with low-intermediate risk of CAD, "ischaemic" ECG changes during vasodilator stress combined with normal MPS are encountered mostly in women and are associated with a low prevalence of significant CAD and a low cardiac event rate.

Abstract 18292: Storm Preparations: Use of Carotid Ultrasound for Assessment of Atherosclerotic Disease

Background: A call of warning was raised by scientists at the 2010 American Heart Association meeting: “Cardiovascular Disease in the Elderly is the Coming Tsunami.” Accordingly, the need to develop imaging modalities to detect coronary artery disease (CAD) early was identified. Carotid intimal medial thickening (CIMT) may serve as a systemic barometer of atherosclerosis throughout the arterial tree. Plaque is also often observed in the carotid arteries of patients however its association with CAD is unclear. Our objective was to determine the sensitivity and negative predictive value of CIMT and carotid plaque in consecutive outpatients referred for angiography. Methods: Carotid scans were conducted immediately following the angiogram in 242 consecutive outpatients. An ultrasonography device (General Electric Vivid 7; USA) equipped with a 10 MHz linear probe was used to record images from both the right and left carotid arteries. CIMT in the distal common carotid artery and the maximal two-dimensional thickness of carotid bulb plaque was measured. The angiogram was scored as 0 (no coronary lesions), 1 (mild coronary atherosclerosis), 2 (at least 50% narrowing in one vessel), and 3 (at least 50% narrowing in two or more vessels). Sensitivity and negative predictive value of CIMT &lt; 1mm and of plaque &lt; 1.5 mm was determined for an angiogram score of 0 or 1. Results: The prevalence of significant CAD in this population was 71%. The average CIMT for men was 0.94 +/− 0.22 mm and for women was 0.88 +/− 0.19 mm. The mean maximum plaque value was 2.31 +/− 0.95 mm for men, and 2.03 +/− 1.01 mm for women. Plaque thickness but not CIMT was greater in patients with CAD (p&lt; 0.001). The negative predictive value of CIMT was poor (&lt; 50%) however the sensitivity and negative predictive value of plaque was 94 and 75 % respectively. Conclusion: A complete carotid ultrasound that includes plaque assessment may serve as an inexpensive and low-risk test to help rule out CAD in outpatients.

Autopsy investigation and Bayesian approach to coronary artery disease in victims of motor-vehicle accidents

BackgroundEach year, 1.2 million people die worldwide as a result of motor-vehicle accidents (MVA), representing a tremendous burden to healthcare. The aim of this study was to define the prevalence of coronary disease and its possible role in motor-vehicle accidents. Methods and resultsWe examined consecutive cases of non-hospital sudden death autopsies in the area of West Quebec during the period of 2002–2006, and we focused on those victims of MVA. Severe coronary artery disease (CAD) was defined as a narrowing of ≥75% of a cross-sectional area or the presence of acute plaque events in major epicardial coronary arteries. From a total cohort of 1260 autopsies, MVA were responsible for 123 deaths, 100 of whom were men and 23 were women. Significant CAD was documented in approximately 37% of these cases. In individuals older than 60 years, the prevalence of significant CAD and ischemia were 86.2% and 19.8%, respectively. A percentage of 40% of the coronary patients showed erratic driving before the accident, as observed by witnesses. Statistical analysis showed that an individual affected by CAD has 9% probability of suffering a motor-vehicle accident. ConclusionsThe prevalence of severe CAD and acute myocardial ischemia is very high among individuals who have suffered a MVA. Our data suggest the hypothesis that acute CAD could be the cause of accidents in a large group of the drivers affected by coronary disease. For these reasons CAD could be investigated in drivers above 50 years old, as a possible preventive measure and determinant of individual risk stratification.

Positive predictive value of computed tomography coronary angiography in clinical practice

BackgroundSeveral studies have investigated the diagnostic performance of computed tomography coronary angiography (CTCA) for the detection of significant coronary artery disease (CAD). These studies were performed in patients that were already referred for invasive coronary angiography (ICA) and prevalence of significant CAD was high. Although the negative predictive value of CTCA was consistently high, a wide range of positive predictive values (PPVs) was reported. Thus, the PPV of CTCA in patients that undergo CTCA as part of a clinical diagnostic evaluation remains unclear. This study investigated the PPV of CTCA for the detection of significant CAD in clinical practice. MethodsA total of 181 patients with low to intermediate pre-test probability CAD that were referred for non-invasive evaluation of chest pain underwent 64-slice CTCA. CTCA was scored per segment as normal, non-obstructive CAD or obstructive CAD (>50% diameter stenosis). All patients with obstructive CAD according to CTCA, underwent ICA. Significant CAD was defined as >50% diameter stenosis on ICA. ResultsAccording to CTCA, 65 (35.9%) patients had obstructive CAD. In 26 (14.4%) patients, significant CAD was found by ICA. The PPV for detection of significant CAD per patient, per vessel and per segment were 40.0% (26/65, 95% CI: 30.6–50.2%), 31.3% (36/115, 95% CI: 24.7–38.8%) and 25.5% (42/165; 95% CI: 20.3–31.4%), respectively. ConclusionsThe PPV of CTCA for detection of significant CAD in patients with low to intermediate probability CAD that are clinically referred for non-invasive evaluation of chest pain is markedly lower than generally reported.