Probability Of Coronary Artery Disease Research Articles

CRT-200.01 Immune Cells in Tunica Media and Extent of Diffuse Atherosclerotic Process in Coronary Arteries Disease

In the last decades morphologic investigations of coronary artery disease (CAD) have been mainly focused on histological changes in intimal endothelial cells and subendothelial space, whereas in the last years there is growing interest in histological changes of other layers of the vascular wall in

Zero Calcium Score as a Filter for Further Testing in Patients Admitted to the Coronary Care Unit with Chest Pain.

BackgroundThe accuracy of zero coronary calcium score as a filter in patients with chest pain has been demonstrated at the emergency room and outpatient clinics, populations with low prevalence of coronary artery disease (CAD).ObjectiveTo test the gatekeeping role of zero calcium score in patients with chest pain admitted to the coronary care unit (CCU), where the pretest probability of CAD is higher than that of other populations.MethodsPatients underwent computed tomography for calcium scoring, and obstructive CAD was defined by a minimum 70% stenosis on invasive angiography.ResultsIn 146 patients studied, the prevalence of CAD was 41%. A zero calcium score was present in 35% of the patients. The sensitivity and specificity of zero calcium score yielded a negative likelihood ratio of 0.16. After logistic regression adjustment for pretest probability, zero calcium score was independently associated with lower odds of CAD (OR = 0.12, 95%CI = 0.04-0.36), increasing the area under the ROC curve of the clinical model from 0.76 to 0.82 (p = 0.006). Zero calcium score provided a net reclassification improvement of 0.20 (p = 0.0018) over the clinical model when using a pretest probability threshold of 10% for discharging without further testing. In patients with pretest probability < 50%, zero calcium score had a negative predictive value of 95% (95%CI = 83%-99%), with a number needed to test of 2.1 for obtaining one additional discharge.ConclusionZero calcium score substantially reduces the pretest probability of obstructive CAD in patients admitted to the CCU with acute chest pain. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

A Multivariate Model for Prediction of Obstructive Coronary Disease in Patients with Acute Chest Pain: Development and Validation.

BackgroundCurrently, there is no validated multivariate model to predict probability of obstructive coronary disease in patients with acute chest pain.ObjectiveTo develop and validate a multivariate model to predict coronary artery disease (CAD) based on variables assessed at admission to the coronary care unit (CCU) due to acute chest pain.MethodsA total of 470 patients were studied, 370 utilized as the derivation sample and the subsequent 100 patients as the validation sample. As the reference standard, angiography was required to rule in CAD (stenosis ≥ 70%), while either angiography or a negative noninvasive test could be used to rule it out. As predictors, 13 baseline variables related to medical history, 14 characteristics of chest discomfort, and eight variables from physical examination or laboratory tests were tested.ResultsThe prevalence of CAD was 48%. By logistic regression, six variables remained independent predictors of CAD: age, male gender, relief with nitrate, signs of heart failure, positive electrocardiogram, and troponin. The area under the curve (AUC) of this final model was 0.80 (95% confidence interval [95%CI] = 0.75 - 0.84) in the derivation sample and 0.86 (95%CI = 0.79 - 0.93) in the validation sample. Hosmer-Lemeshow's test indicated good calibration in both samples (p = 0.98 and p = 0.23, respectively). Compared with a basic model containing electrocardiogram and troponin, the full model provided an AUC increment of 0.07 in both derivation (p = 0.0002) and validation (p = 0.039) samples. Integrated discrimination improvement was 0.09 in both derivation (p < 0.001) and validation (p < 0.0015) samples.ConclusionA multivariate model was derived and validated as an accurate tool for estimating the pretest probability of CAD in patients with acute chest pain.

An Audit on the Appropriateness of Coronary Computed Tomography Angiography Referrals in a Tertiary Cardiac Center.

Background:In response to growing concerns regarding the overuse of coronary computed tomography angiography (CCTA) in the clinical setting, multiple societies, including the American College of Cardiology Foundation, have jointly published revised criteria regarding the appropriate use of this imaging modality. However, previous research indicates significant discrepancies in the rate of adherence to these guidelines.Aim:To assess the appropriateness of CCTA referrals in a tertiary cardiac center in Bahrain.Methods:This retrospective clinical audit examined the records of patients referred to CCTA between the April 1, 2015 and December 31, 2015 in Mohammed bin Khalifa Cardiac Center. Using information from medical records, each case was meticulously audited against guidelines to categorize it as appropriate, inappropriate, or uncertain.Results:Of the 234 records examined, 176 (75.2%) were appropriate, 47 (20.1%) were uncertain, and 11 (4.7%) were inappropriate. About 74.4% of all referrals were to investigate coronary artery disease (CAD). The most common indication that was deemed appropriate was the detection of CAD in the setting of suspected ischemic equivalent in patients with an intermediate pretest probability of CAD (65.9%). Most referrals deemed inappropriate were requested to detect CAD in asymptomatic patients at low or intermediate risk of CAD (63.6%).Conclusion:This audit demonstrates a relatively low rate of inappropriate CCTA referrals, indicating the appropriate and efficient use of this resource in the Mohammed bin Khalifa Cardiac Center. Agreement on and reclassification of “uncertain” cases by guideline authorities would facilitate a deeper understanding of referral appropriateness.

Accuracy of gestalt perception of acute chest pain in predicting coronary artery disease.

AIMTo test accuracy and reproducibility of gestalt to predict obstructive coronary artery disease (CAD) in patients with acute chest pain.METHODSWe studied individuals who were consecutively admitted to our Chest Pain Unit. At admission, investigators performed a standardized interview and recorded 14 chest pain features. Based on these features, a cardiologist who was blind to other clinical characteristics made unstructured judgment of CAD probability, both numerically and categorically. As the reference standard for testing the accuracy of gestalt, angiography was required to rule-in CAD, while either angiography or non-invasive test could be used to rule-out. In order to assess reproducibility, a second cardiologist did the same procedure.RESULTSIn a sample of 330 patients, the prevalence of obstructive CAD was 48%. Gestalt’s numerical probability was associated with CAD, but the area under the curve of 0.61 (95%CI: 0.55-0.67) indicated low level of accuracy. Accordingly, categorical definition of typical chest pain had a sensitivity of 48% (95%CI: 40%-55%) and specificity of 66% (95%CI: 59%-73%), yielding a negligible positive likelihood ratio of 1.4 (95%CI: 0.65-2.0) and negative likelihood ratio of 0.79 (95%CI: 0.62-1.02). Agreement between the two cardiologists was poor in the numerical classification (95% limits of agreement = -71% to 51%) and categorical definition of typical pain (Kappa = 0.29; 95%CI: 0.21-0.37).CONCLUSIONClinical judgment based on a combination of chest pain features is neither accurate nor reproducible in predicting obstructive CAD in the acute setting.

Computed tomography versus invasive coronary angiography: design and methods of the pragmatic randomised multicentre DISCHARGE trial.

More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266). In this trial, patients with a low-to-intermediate pretest probability (10-60%) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines. Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences. The DISCHARGE trial will assess the comparative effectiveness of CT and ICA. • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD.

Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care

ObjectiveTo construct a clinical prediction rule for coronary artery disease (CAD) presenting with chest pain in primary care. Study Design and SettingMeta-Analysis using 3,099 patients from five studies. To identify candidate predictors, we used random forest trees, multiple imputation of missing values, and logistic regression within individual studies. To generate a prediction rule on the pooled data, we applied a regression model that took account of the differing standard data sets collected by the five studies. ResultsThe most parsimonious rule included six equally weighted predictors: age ≥55 (males) or ≥65 (females) (+1); attending physician suspected a serious diagnosis (+1); history of CAD (+1); pain brought on by exertion (+1); pain feels like “pressure” (+1); pain reproducible by palpation (−1). CAD was considered absent if the prediction score is <2. The area under the ROC curve was 0.84. We applied this rule to a study setting with a CAD prevalence of 13.2% using a prediction score cutoff of <2 (i.e., −1, 0, or +1). When the score was <2, the probability of CAD was 2.1% (95% CI: 1.1–3.9%); when the score was ≥ 2, it was 43.0% (95% CI: 35.8–50.4%). ConclusionsClinical prediction rules are a key strategy for individualizing care. Large data sets based on electronic health records from diverse sites create opportunities for improving their internal and external validity. Our patient-level meta-analysis from five primary care sites should improve external validity. Our strategy for addressing site-to-site systematic variation in missing data should improve internal validity. Using principles derived from decision theory, we also discuss the problem of setting the cutoff prediction score for taking action.

Left ventricular torsion and circumferential strain responses to exercise in patients with ischemic coronary artery disease.

LV torsion during exercise in patients with coronary artery disease (CAD) is not well known. Circumferential strain (CS) and left ventricular (LV) torsion (Tor) have not been evaluated during ischemia in these patients. We aimed to assess the effect of ischemia during exercise echocardiography (ExE) on CS and Tor. We studied a group of 73 patients with true positive ExE results (Ischemic group: ischemia plus an abnormal coronary angiogram) and a matched control group of 66 patients with negative ExE and either normal coronary angiography or low post-test probability of CAD. Basal rotation (Rot) and apical rotation and basal and apical CS were studied by speckle tracking at rest and exercise. Apical CS and apical and basal Rot values were similar between groups at rest, except basal CS which was already worse in the ischemic group. At exercise, all rotational and CS parameters were impaired in the ischemic in comparison with the control group (basal CS: -18 ± 5 vs. -25 ± 7 %, p < 0.001; apical CS: -31 ± 11 vs. - 43 ± 9 %, p < 0.001; time to basal CS: 52 ± 6 vs. 48 ± 7 %, p = 0.001; time to apical CS: 55 ± 7 vs. 49 ± 6 %, p < 0.001; basal rotation: -0.7 ± 6.5° vs. -6.2 ± 8.5°, p < 0.001; LV twist 13.0 ± 10.4° vs.19.7 ± 11.5°, p < 0.001; LV-Tor 1.9 ± 1.6°/cm vs. 2.8 ± 1.7˚/cm, p = 0.001) with the exception of apical rotation which was similar (12.3 ± 7.4° vs. 13.4 ± 7.7°, p = NS). Basal and apical CS and basal rotation impair during exercise-induced ischemia. LV-Tor decreases with ischemia due to worsening of basal rotation, whereas apical rotation does not impair, suggesting the existence of an apical compensatory mechanism.

Pre-test probability of obstructive coronary stenosis in patients undergoing coronary CT angiography: Comparative performance of the modified diamond-Forrester algorithm versus methods incorporating cardiovascular risk factors

BackgroundCurrent guidelines recommend the use of the Modified Diamond-Forrester (MDF) method to assess the pre-test likelihood of obstructive coronary artery disease (CAD). We aimed to compare the performance of the MDF method with two contemporary algorithms derived from multicenter trials that additionally incorporate cardiovascular risk factors: the calculator-based ‘CAD Consortium 2’ method, and the integer-based CONFIRM score. MethodsWe assessed 1069 consecutive patients without known CAD undergoing coronary CT angiography (CCTA) for stable chest pain. Obstructive CAD was defined as the presence of coronary stenosis ≥50% on 64-slice dual-source CT. The three methods were assessed for calibration, discrimination, net reclassification, and changes in proposed downstream testing based upon calculated pre-test likelihoods. ResultsThe observed prevalence of obstructive CAD was 13.8% (n=147). Overestimations of the likelihood of obstructive CAD were 140.1%, 9.8%, and 18.8%, respectively, for the MDF, CAD Consortium 2 and CONFIRM methods. The CAD Consortium 2 showed greater discriminative power than the MDF method, with a C-statistic of 0.73 vs. 0.70 (p<0.001), while the CONFIRM score did not (C-statistic 0.71, p=0.492).Reclassification of pre-test likelihood using the ‘CAD Consortium 2’ or CONFIRM scores resulted in a net reclassification improvement of 0.19 and 0.18, respectively, which would change the diagnostic strategy in approximately half of the patients. ConclusionsNewer risk factor-encompassing models allow for a more precise estimation of pre-test probabilities of obstructive CAD than the guideline-recommended MDF method. Adoption of these scores may improve disease prediction and change the diagnostic pathway in a significant proportion of patients.

Prognostic value of coronary artery calcium score in patients with symptoms suggestive of coronary artery disease. Results from the Silesian Calcium Score (SILICAS) study.

INTRODUCTION The prognostic value of coronary artery calcium score (CACS) in symptomatic patients with a suspicion of coronary artery disease (CAD) has been poorly defined. OBJECTIVES The aim of the study was to assess the predictive value of the CACS in the incidence of major adverse coronary events (MACEs) in patients with an intermediate probability of CAD and establish its usefulness as the first-line risk assessment tool. PATIENTS AND METHODS This single-center, observational, prospective study enrolled consecutive symptomaticpatients without a previous diagnosis of CAD, referred to our center for CACS assessment with non-contrast-enhanced cardiac computed tomography (CT). CACS measurements were performed using an electrocardiogram-gated 64-row CT scanner. The CACS measurement was treated as the first‑line noninvasive test. Patients with positive CACS values were divided into 4 subgroups: <100 Agatston units (AU), 100 to 399 AU; 400 to 999 AU; and ≥1000 AU. The incidence of MACEs was analyzed in 2 ways: negative versus positive CACS and by the CACS subgroups. RESULTS We included 588 patients (mean age, 61.1 ±9.7 years; women, 64%). The median follow-up period was 707 days. There were 239 patients (49.3%) with no coronary calcium. In these patients, no MACEs were observed, while in those with positive CACS values, they occurred in 108 patients (30.9%) (P <0.001). The incidence of MACEs was dependent on the CACS values, reaching 91% in those with a CACS of 1000 or higher AU. CONCLUSIONS In selected symptomatic patients with an intermediate probability of CAD, the CACS measurement may be used as the first-line test to assess the risk of MACEs.

Early and late diastolic strain rate vs global longitudinal strain at rest and during dobutamine stress for the assessment of significant coronary artery stenosis in patients with a moderate and high probability of coronary artery disease.

The aim of this prospective study was to assess the usefulness of global longitudinal strain (GLS), regional diastolic and systolic strain, strain rate (SR) parameters at rest and during dobutamine stress echocardiography for detecting significant coronary artery stenosis in patients with a moderate or high probability of coronary artery disease (CAD). Dobutamine stress echocardiography and adenosine magnetic resonance imaging (AMRI) were performed on 127 patients with a moderate and high probability of CAD and left ventricle ejection fraction ≥55%. CAD was defined as ≥70% diameter stenosis on coronary angiography validated as hemodynamically significant by AMRI. Patients were grouped according to coronary angiography and AMRI results: CAD (-) n=67 (52.8%) vs CAD (+) n=60 (47.2%). There were no significant differences of clinical characteristics, conventional echocardiography, and deformation parameters between the two groups at rest except that GLS was higher in the CAD (-) group (-21.5±2.4% vs -16.2±2.1%, P=.00). GLS at high dobutamine doses had the highest area under the ROC curve (AUC) (AUC 0.955, sensitivity 94%, specificity 92%). Radial late diastolic SR at low doses performed best out of all diastolic parameters with an AUC of 0.789, sensitivity 76.7%, specificity 91.7%. Other deformation parameters including visual assessment were inferior. Global longitudinal strain is highly sensitive and specific in detecting hemodynamically significant coronary artery stenosis in moderate- to high-risk patients without known CAD. This is the first study showing that GLS is more sensitive and specific compared with early and late diastolic SR parameters or visual assessment in detecting CAD.

Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review.

Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality globally. The most cost-effective imaging strategy to diagnose CAD in patients with stable chest pain is however uncertain. To review the evidence on comparative cost-effectiveness of different imaging strategies for patients presenting with stable chest pain symptoms suggestive for CAD. Systematic review. Studies performing a formal economic evaluation or decision analysis in the English language published between January 1995 and December 2015 were identified using PubMed, Medline (OvidSP), Embase, Web of Science, Cochrane economic evaluations library, and EconLit. Reviews and meta-analyses were excluded. Two independent reviewers assessed titles and abstracts. Of the 4498 titles identified, 70 met our selection criteria. One reviewer used a modified version of the CHEERS checklist to assess study quality. One reviewer extracted data on study details, which were checked by a second reviewer. There is a major heterogeneity between the available cost-effectiveness studies included in this study. The included studies compared very different testing strategies in very different ways and provided mostly short-term results. Strategies of no-testing and xECG were underrepresented. Nonetheless, the findings from this systematic review suggest that for patients with a low to intermediate prior probability of having obstructive CAD, computed tomography coronary angiography (CTCA) may be cost-effective as an initial diagnostic imaging test in comparison with CAG or other non-invasive diagnostic tests. If functional testing is required, stress echocardiography (SE) or single-photon emission computed tomography (SPECT) are suggested to be cost-effective initial strategies in patients with intermediate prior probability of CAD. Yet, other functional testing strategies such as xECG and positron-emission tomography (PET) scanning have not been studied as intensely. Immediate CAG is suggested to be a cost-effective strategy for patients at a high prior probability of having obstructive CAD whom may benefit from revascularization. The study emphasizes the inextricable link between clinical effectiveness and economic efficiency. Evidence suggests that the optimal diagnostic imaging strategy for individuals suspected of having CAD is CTCA for low and intermediate disease probability, followed by SE or SPECT as necessary, and invasive CAG for high disease probability. Further studies are needed to evaluate the cost-effectiveness of alternative non-invasive tests, including a no-testing strategy.

Predictors of high-risk coronary artery disease in subjects with normal SPECT myocardial perfusion imaging

BackgroundWhile uncommon, normal stress SPECT myocardial perfusion imaging (MPI) can be seen in patients with high-risk coronary artery disease (CAD) by invasive coronary angiography (ICA).The predictors of high-risk CAD in patients with normal SPECT-MPI have not been described. MethodsWe studied 580 patients (age 64 ± 12 years, 49% men) without known CAD who underwent stress-gated SPECT-MPI [exercise (41%) or vasodilator (59%)] <2 months before ICA and had summed stress score (SSS) <4. High-risk CAD was defined as 3 vessels with ≥70% stenosis, 2 vessels with ≥70% stenosis including proximal left anterior descending, or left main with ≥50% stenosis. Obstructive non-high-risk CAD was defined by the presence of a ≥70% stenosis but without having other high-risk criteria. Tenfold cross-validated receiver operating characteristic (ROC) estimates were obtained to assess the predictors of high-risk CAD. ResultsForty-two subjects (7.2%) had high-risk CAD and 168 (29.0%) had obstructive non-high-risk CAD. Variables associated with high-risk CAD were pretest probability of CAD ≥66% (Odds ratio [OR] 3.63, 95% CI 1.6-8.3, P = .002), SSS > 0 (OR 7.46, 95% CI 2.6-21.1, P < 0.001), and abnormal TID (OR 2.16, 95% CI 1.0-4.5, P = 0.044). When substituted for TID, EF change was also predictive of high-risk CAD (OR 0.93, 95% CI 0.9-1.0, P = 0.023). The prevalence of high-risk CAD increased as the number of these predictors increased. In a sub-analysis of patients in whom quantitative total perfusion deficit (TPD) was available, TPD > 0 was also a predictor of high-risk CAD (OR 6.01, 95% CI 1.5-22.2, P = 0.011). ConclusionSeveral clinical, stress, and SPECT-MPI findings are associated high-risk CAD among patients with normal SPECT-MPI. Consideration of these factors may improve the overall assessment of the likelihood of high-risk CAD in patients undergoing stress SPECT-MPI.

The PLATFORM Trial: An Insight into the Improved Value of Using FFRCT for Reduction of Invasive Angiographic Procedures

Page e13 Coronary CT Angiography (CCTA) has been widely used as a reliable non-invasive modality for the diagnosis of Coronary Artery Disease (CAD) due to its improved spatial and temporal resolution.1-5 For patients with low to intermediate pre-test probability of CAD, CCTA is used as an effective gatekeeper for determination of downstream testing, such as invasive coronary angiography or functional imaging.6 However, CCTA is mainly an anatomic test with excellent visualization of coronary anatomical structures and detection of coronary lumen stenosis, while providing little functional information of the coronary lesions. Despite high sensitivity and negative predictive value, CCTA has been reported to have moderate specificity and positive predictive value due to the high percentage of false positive rates, and this is especially apparent in the assessment of coronary arteries with heavy calcification. Studies have shown the limited diagnostic value of CCTA in diagnosing highly calcified coronary plaques.7-11 Thus, an imaging technique able to detect ischemia-producing lesions is of paramount importance since coronary stenosis does not always translate to functional significance. Clinical decision making of whether patients should proceed to a revascularization procedure is based on the predictive functional effect of coronary stenosis, because no prognostic benefit of revascularization has been reported in the coronary lesions without functional significance.12,13

Diagnostic Performance and Clinical Utility of Myocardial Perfusion MRI for Coronary Artery Disease with Fractional Flow Reserve as the Standard Reference: A Meta-analysis

Stress myocardial perfusion imaging is a noninvasive alternative to invasive fractional flow reserve for evaluating haemodynamically significant coronary artery disease. We aimed to systematically analyse the diagnostic performance and clinical utility of myocardial perfusion MRI for coronary artery disease (CAD) using fractional flow reserve (FFR) as the standard reference. We searched PubMed, EMBASE, and Cochrane Library to July 2015 for studies using perfusion MR as a diagnostic test for CAD versus FFR. The meta-analysis was performed based on Cochrane guideline. We identified 20 studies with 1,570 patients. Pooled analyses were performed at per-patient level (1,041 patients) and per-territory level (2,690 coronary territories). The sensitivity, specificity, area under sROC curve were 0.88 (95% CI: 0.85, 0.91), 0.88 (95% CI: 0.84, 0.90), and 0.94 (95% CI: 0.92, 0.96) at per-patient level, and 0.86 (95% CI: 0.81, 0.90), 0.88 (95% CI: 0.84, 0.92), and 0.93 (95% CI: 0.91, 0.95) at per-territory level. Post-test probability was altered by positive (likelihood ratio) LR of 7.1 (95% CI: 5.6, 9.0) and negative LR of 0.13 (95% CI: 0.10, 0.17) based on Bayes' theorem. Diagnostic accuracy of myocardial perfusion MRI for CAD is high and can alter the post-test probability of CAD.

Sex Differences in Demographics, Risk Factors, Presentation, and Noninvasive Testing in Stable Outpatients With Suspected Coronary Artery Disease: Insights From the PROMISE Trial

ObjectivesThe aim of this study was to determine whether presentation, risk assessment, testing choices, and results differ by sex in stable symptomatic outpatients with suspected coronary artery disease (CAD). BackgroundAlthough established CAD presentations differ by sex, little is known about stable, suspected CAD. MethodsThe characteristics of 10,003 men and women in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial were compared using chi-square and Wilcoxon rank-sum tests. Sex differences in test selection and predictors of test positivity were examined using logistic regression. ResultsWomen were older (62.4 years of age vs. 59.0 years of age) and were more likely to be hypertensive (66.6% vs. 63.2%), dyslipidemic (68.9% vs. 66.3%), and to have a family history of premature CAD (34.6% vs. 29.3) (all p values <0.005). Women were less likely to smoke (45.6% vs. 57.0%; p < 0.001), although their prevalence of diabetes was similar to that in men (21.8% vs. 21.0%; p = 0.30). Chest pain was the primary symptom in 73.2% of women versus 72.3% of men (p = 0.30), and was characterized as “crushing/pressure/squeezing/tightness” in 52.5% of women versus 46.2% of men (p < 0.001). Compared with men, all risk scores characterized women as being at lower risk, and providers were more likely to characterize women as having a low (<30%) pre-test probability of CAD (40.7% vs. 34.1%; p < 0.001). Compared with men, women were more often referred to imaging tests (adjusted odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44) than nonimaging tests. Women were less likely to have a positive test (9.7% vs. 15.1%; p < 0.001). Although univariate predictors of test positivity were similar, in multivariable models, age, body mass index, and Framingham risk score were predictive of a positive test in women, whereas Framingham and Diamond and Forrester risk scores were predictive in men. ConclusionsPatient sex influences the entire diagnostic pathway for possible CAD, from baseline risk factors and presentation to noninvasive test outcomes. These differences highlight the need for sex-specific approaches for the evaluation of CAD.

Diagnostic value of ischemia severity at myocardial perfusion imaging in elderly persons with suspected coronary disease.

Myocardial perfusion and ischemia scores obtained from myocardial perfusion scintigraphy (MPS) have strong independent prognostic value in elderly individuals without known coronary artery disease (CAD). Herein we aimed to assess their independent diagnostic value and accuracy for CAD while considering different thresholds of myocardial ischemia. We estimated the summed rest score (SRS), summed stress score (SSS) and summed difference score (SDS) in 322 elderly individuals (mean age 72 ± 7 years, 68% men) who underwent coronary angiography following an MPS. Abnormal perfusion at stress was defined as an SSS greater than 3, and ischemia as an SDS of at least 2, and further categorized as mild (2-4), moderate (5-7) or severe (>7). Multivariate logistic regressions were used to establish the independent diagnostic value and accuracy of MPS parameters. CAD was diagnosed in 182 individuals (56%). In multivariate analysis accounting for clinical variables associated with CAD including the Framingham risk score, both SRS [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.01-1.18, P = 0.03] and SSS (OR 1.10, 95% CI 1.04-1.16, P = 0.0006) and SDS (OR 1.12, 95% CI 1.04-1.21, P = 0.003) were independently associated with CAD. An SSS greater than 3 was also independently associated with CAD (OR 2.51, 95% CI 1.43-4.39, P = 0.0013), whereas an SDS of 2 or greater was not (OR 1.62, 95% CI 0.89-2.93, P = 0.12), but only when at least 5 (OR 2.31, 95% CI 1.32-4.03, P = 0.003). The probability of CAD was proportional to the amount of myocardial ischemia in those with an SSS greater than 3, and lower and comparable in those with an SSS of at least 3 or an SSS greater than 3 with SDS of 1 or less (P = 0.19). Increasing the threshold of myocardial ischemia determined a decrease in sensitivity and increase in specificity of MPS for both diagnosis and severity of CAD. We established the diagnostic value and accuracy of continuous scores and thresholds of abnormal myocardial perfusion and ischemia previously validated in prognostic studies. Their more widespread use could potentially improve the diagnostic yield of coronary angiography in elderly individuals with suspected CAD.

Coronary Artery Calcium as an Independent Surrogate Marker in the Risk Assessment of Patients With Atrial Fibrillation and an Intermediate Pretest Likelihood for Coronary Artery Disease Admitted to a German Chest Pain Unit.

About 10% of patients admitted to a chest pain unit (CPU) exhibit atrial fibrillation (AF). To determine whether calcium scores (CS) are superior over common risk scores for coronary artery disease (CAD) in patients presenting with atypical chest pain, newly diagnosed AF, and intermediate pretest probability for CAD within the CPU. In 73 subjects, CS was related to the following risk scores: Global Registry of Acute Coronary Events (GRACE) score, including a new model of a frequency-normalized approach; Thrombolysis In Myocardial Infarction score; European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE); Framingham risk score; and Prospective Cardiovascular Münster Study score. Revascularization rates during index stay were assessed. Median CS was 77 (interquartile range, 1-270), with higher values in men and the left anterior descending artery. Only the modified GRACE (ρ = 0.27; P = 0.02) and the SCORE (ρ = 0.39; P < 0.005) were significantly correlated with CS, whereas the GRACE (τ = 0.21; P = 0.04) and modified GRACE (τ = 0.23; P = 0.02) scores were significantly correlated with percentile groups. Only the CS significantly discriminated between those with and without stenosis (P < 0.01). Apart from modified GRACE score, overall correlations between risk scores and calcium burden, as well as revascularization rates during index stay, were low. By contrast, the determination of CS may be used as an additional surrogate marker in risk stratification in AF patients with intermediate pretest likelihood for CAD admitted to a CPU.

Independent prognostic value of coronary artery calcium score and coronary computed tomography angiography in an outpatient cohort of low to intermediate risk chest pain patients.

BackgroundLimited studies report on the additional prognostic value of coronary computed tomography angiography (CCTA) and the coronary artery calcium score (CACS).MethodsFor a median of 637 days, 1551 outpatients with chest pain, without known coronary artery disease (CAD) and low or intermediate pre-test probability of CAD, were followed for major adverse cardiac events (MACE), defined as death, myocardial infarction or late revascularisation. Cox proportional hazard regression was used to evaluate the independent prognostic value of CCTA and CACS.ResultsMACE occurred in 23 patients (1.5 %): death (3, 0.2 %), myocardial infarction (4, 0.3 %) and late revascularisation (16, 1.3 %). Multivariate analysis showed an independent prognostic value of CCTA (p < 0.001), CACS of 100–400 (p = 0.035) and CACS of > 400 (p = 0.021). CCTA showed obstructive CAD in 3.1 % of patients with CACS = 0. No events occurred in patients with CACS = 0 without obstructive CAD at CCTA, whereas 2/23 patients (9 %) with CACS = 0 with obstructive CAD had a MACE.ConclusionsOur study shows that both CCTA and higher CACS categories have independent prognostic value in chest pain patients with low to intermediate pre-test probability of obstructive CAD, in which CCTA is appropriate. Furthermore a non-negligible amount of patients with CACS = 0 have obstructive CAD at CCTA. CCTA can be used in these patients to identify those at risk for MACE.

Two-Dimensional Speckle-Tracking during Dobutamine Stress Echocardiography in the Detection of Myocardial Ischemia in Patients with Suspected Coronary Artery Disease

Two-dimensional speckle-tracking applied to dobutamine stress echocardiography (DSE) may aid in the detection of coronary artery disease (CAD). The aim of this study was to determine the value of strain, strain rate, and postsystolic strain index (PSI) measured by speckle-tracking during DSE in the evaluation of the presence, extent, and severity of myocardial ischemia. Fifty patients 63±7years of age with intermediate probability of CAD were prospectively recruited. All patients underwent DSE, quantitative positron emission tomographic perfusion imaging, and invasive angiography. Regional peak systolic longitudinal strain, strain rate, and PSI were measured at rest, at a dobutamine dose of 20μg/kg/min, at peak stress, and at early recovery (1min after stress). Obstructive CAD was defined as >75% stenosis or 40% to 75% stenosis combined with either fractional flow reserve<0.80 or abnormal findings on myocardial perfusion positron emission tomography. Obstructive CAD was detected in 22 patients and in 36 of 150 coronary arteries. Strain analyses showed the highest reproducibility at rest, at a dobutamine dose of 20μg/kg/min, and at early recovery. Increased PSI and reduced strain during early recovery were the strongest predictors of obstructive CAD and were associated with the extent, localization, and depth of myocardial ischemia by positron emission tomography. On vessel-based analysis, strain, PSI, and visual analysis of wall motion provided comparable diagnostic accuracy, whereas the combination of strain or PSI with visual analysis provided incremental value over visual analysis alone. Assessment of systolic or postsystolic strain by speckle-tracking echocardiography during early recovery after DSE can help in the detection of hemodynamically significant coronary stenosis compared with visual wall motion analysis alone.