Coronary CT Angiography Results Research Articles

Coronary Artery Disease Assessment via On-Site CT Fractional Flow Reserve in Patients Undergoing Transcatheter Aortic Valve Replacement.

Purpose To examine the clinical feasibility of workstation-based CT fractional flow reserve (CT-FFR) for coronary artery disease (CAD) evaluation during preprocedural planning in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods In this retrospective single-center study, 434 patients scheduled for TAVR between 2018 and 2020 were screened for study inclusion; a relevant proportion of patients (35.0% [152 of 434]) was not suitable for evaluation due to insufficient imaging properties. A total of 112 patients (mean age, 82.1 years ± 6.7 [SD]; 58 [52%] men) were included in the study. Invasive angiography findings, coronary CT angiography results, and Agatston score were acquired and compared with on-site CT-FFR computation for evaluation of CAD and prediction of major adverse cardiovascular events (MACE) within a 24-month follow-up. Results Hemodynamic relevant CAD, as suggested by CT-FFR of 0.80 or less, was found in 41 of 70 (59%) patients with stenosis of 50% or more. MACE occurred in 23 of 112 (20.5%) patients, from which 14 of 23 had stenoses with CT-FFR of 0.80 or less (hazard ratio [HR], 3.33; 95% CI: 1.56, 7.10; P = .002). CT-FFR remained a significant predictor of MACE after inclusion in a multivariable model with relevant covariables (HR, 2.89; 95% CI: 1.22, 6.86; P = .02). An Agatston score of 1000 Agatston units or more (HR, 2.25; 95% CI: 0.98, 5.21; P = .06) and stenoses of 50% or more determined via invasive angiography (HR, 0.94; 95% CI: 0.41, 2.17; P = .88) were not significant predictors of MACE. Conclusion Compared with conventional CAD markers, CT-FFR better predicted adverse outcomes after TAVR. A relevant portion of the screened cohort, however, was not suitable for CT-based CAD evaluation. Keywords: CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Coronary Arteries, Outcomes Analysis © RSNA, 2024 See also the commentary by Weir-McCall and Pugliese in this issue.

Assessment of Coronary Stenosis Using Coronary CT Angiography in Patients with High Calcium Scores: Current Limitations and Future Perspectives

Coronary CT angiography (CCTA) is recognized for its role as a gatekeeper for invasive coronary angiography in patients suspected of coronary artery disease because it can detect significant coronary stenosis with high accuracy. However, heavy plaque in the coronary artery makes it difficult to visualize the lumen, which can lead to errors in the interpretation of the CCTA results. This is primarily due to the limited spatial resolution of CT scanners, resulting in blooming artifacts caused by calcium. However, coronary stenosis with high calcium scores often requires evaluation using CCTA. Technological methods to overcome these limitations include the introduction of high-resolution CT scanners, the development of reconstruction techniques, and the subtraction technique. Methods to improve reading ability, such as the setting of appropriate window width and height, and evaluation of the position of calcified plaque and residual visibility of the lumen in cross-sectional images, are also recommended.

Choosing between coronary CT angiography and functional tests in patients with suspected coronary artery disease: mind the (gender) gap

Abstract Introduction There is a need for a simple method to choose between a functional vs. anatomical test as first line approach to patients with suspected coronary artery disease (CAD). While European Guidelines base the decision on pretest probability (PTP) without a clear threshold, American Guidelines rely uniquely on age, with a 65-year-old cut-off for both genders. The aims of this study were: 1) to assess the proportion of patients undergoing coronary CT angiography (CCTA) in whom a functional test could have been more suitable due to extensive coronary artery calcification (CAC) and/or inconclusive CCTA results; 2) compare PTP vs. age to predict the presence of these suboptimal conditions for CCTA. Methods Individuals 40-80 years old were identified in a single center registry of patients with stable chest pain or dyspnea who underwent CCTA. Patients with known CAD, severe valvular disease, or irregular heart rhythms were excluded. PTP of obstructive CAD was calculated using age, sex, and symptom typicality. Patients were considered to have suboptimal conditions for CCTA if extensive CAC was present (defined conservatively as an Agatston score >400) or if one or more segments >2mm were deemed non-evaluable despite CAC score ≤ 400. Results A total of 884 patients (57% women, mean age 62±10 years) were included. Symptoms consisted of chest pain in 705 patients (80%). The median PTP of obstructive CAD was 22% (IQR 14-32). Overall, 162 patients (18%) had suboptimal conditions for CCTA due to CAC score >400 (n=140), or ≥1 non-evaluable segments (n=22). The proportion of patients with suboptimal conditions for CCTA was significantly higher in men than in women (27% vs. 12%, respectively; p<0.001). For both genders, the discriminative power to predict suboptimal CCTA conditions was significantly higher for age than for PTP (c-statistic in men 0.74 vs. 0.64, p<0.001; in women 0.71 vs. 0.62, p=0.012). In every age group, the proportion of patients with suboptimal conditions for CCTA was at least 2 times higher in men than in women, with a 10-15 year gap between genders - Fig. Conclusion Suboptimal conditions for a fully diagnostic CCTA were found in 18% of patients, were more strongly associated with age than with PTP, and were at least 2 times more frequent in men than in women across all age groups. These findings support the use of an age cut-off for anatomical vs. functional testing in men, and the use of CCTA as first line test in most women regardless of age.Proportion of patients suboptimal CCTA

Real-world approach to comprehensive artificial intelligence-aided CT evaluation of coronary artery disease in 530 patients: A retrospective study

PurposeRecent guidelines provide broader support for the use of less invasive imaging modalities for the evaluation of patients with stable chest pain. Coronary CT angiography (CCTA) uses increasingly sophisticated techniques to improve evaluation of coronary lesions. The purpose of this study is to describe one center's experience implementing AI-assisted advanced imaging techniques to diagnose coronary artery disease. Materials & methodsRetrospective study of patients who had AI-assisted CCTA interpretation, including a subgroup who underwent fractional flow reserve CT (FFR-CT) and invasive coronary angiography. Descriptive statistics summarized baseline characteristics and univariate statistics compared findings between groups of patients with and without anatomically and hemodynamically significant lesions based on FFR-CT. For patients who underwent invasive coronary angiography, concordance between CCTA and angiography was evaluated. ResultsOf 532 included patients, AI-assisted CCTA identified statistically significant difference in calcification scores, plaque types and total plaque volume between lesions <50% and ≥50% stenosis. CCTA results were mostly concordant with invasive coronary angiography. Importantly, we identified a subset of patients with less than 50% anatomical stenosis that demonstrated physiologically significant stenosis on FFR-CT and invasive coronary angiography. ConclusionsAI-assisted CCTA and other advanced techniques are a tool to support high quality diagnostic assessment of coronary lesions in a clinical environment. Combined CCTA with FFRCT in mild to moderate coronary stenosis identifies patients with hemodynamically significant stenosis even when quantitative stenosis is <50%. Implementation of AI-assisted coronary CT angiography is feasible in a community hospital setting, but these technologies do not replace the need for expert review and clinical correlation.

Choosing between coronary CT angiography and functional tests in patients with suspected coronary artery disease - mind the (gender) gap

Abstract Funding Acknowledgements Type of funding sources: None. Introduction There is a need for a simple method to choose between a functional vs. anatomical test as first line approach to patients with suspected coronary artery disease (CAD). While European Guidelines base the decision on pretest probability (PTP) without a clear threshold, American Guidelines rely uniquely on age, with a 65-year-old cut-off for both genders. The aims of this study were: 1) to assess the proportion of patients undergoing coronary CT angiography (CCTA) in whom a functional test could have been more suitable due to extensive coronary artery calcification (CAC) and/or inconclusive CCTA results; 2) compare PTP vs. age to predict the presence of these suboptimal conditions for CCTA. Methods Individuals 40–80 years old were identified in a single center registry of patients with stable chest pain or dyspnea who underwent CCTA. Patients with known CAD, severe valvular disease, or irregular heart rhythms were excluded. PTP of obstructive CAD was calculated using age, sex, and symptom typicality. Patients were considered to have suboptimal conditions for CCTA if extensive CAC was present (defined conservatively as an Agatston score &amp;gt;400) or if one or more segments &amp;gt;2mm were deemed non-evaluable despite CAC score ≤ 400. Results A total of 884 patients (57% women, mean age 62±10 years) were included. Symptoms consisted of chest pain in 705 patients (80%). The median PTP of obstructive CAD was 22% (IQR 14–32). Overall, 162 patients (18%) had suboptimal conditions for CCTA due to CAC score &amp;gt;400 (n=140), or ≥1 non-evaluable segments (n=22). The proportion of patients with suboptimal conditions for CCTA was significantly higher in men than in women (27% vs. 12%, respectively; p&amp;lt;0.001). For both genders, the discriminative power to predict suboptimal CCTA conditions was significantly higher for age than for PTP (c-statistic in men 0.74 vs. 0.64, p&amp;lt;0.001; in women 0.71 vs. 0.62, p = 0.012). In every age group, the proportion of patients with suboptimal conditions for CCTA was at least 2 times higher in men than in women, with a 10–15 year gap between genders - Figure 1. Conclusion Suboptimal conditions for a fully diagnostic CCTA were found in 18% of patients, were more strongly associated with age than with PTP, and were at least 2 times more frequent in men than in women across all age groups. These findings support the use of an age cut-off for anatomical vs. functional testing in men, and the use of CCTA as first line test in most women regardless of age.

Coronary CT angiography for preoperative evaluation of non-cardiac surgery in patients with thoracic tumors: preliminary exploratory analysis in a retrospective cohort

PurposeNoninvasive coronary CT angiography (CCTA) was used to retrospectively analyze the characteristics of coronary artery disease (CAD) in patients with thoracic tumors and the impact of the results on clinical surgery decision-making, thus increasing the understanding of perioperative cardiac risk evaluation.MethodA total of 779 patients (age 68.6 ± 6.6 years) with thoracic tumor (lung, esophageal, and mediastinal tumor) scheduled for non-cardiac surgery were retrospectively enrolled. Patients were divided into two groups: accepted or canceled surgery. Clinical data and CCTA results were compared between the two groups, and multivariate logistic regression analysis was performed to determine predictors of the events of cancellations of scheduled surgeries.Results634 patients (81.4%) had non-significant CAD and 145 patients (18.6%) had significant CAD. Single‑, 2‑, and 3‑ vessel disease was found in 173 (22.2%), 93 (11.9%) and 50 (6.4%) patients, respectively. 500 (64.2%), 96 (12.3%), 96 (12.3%), 56 (7.2%) and 31 (4.0%) patients were rated as CACS 0, 1–99, 100–399, 400–999 and > 1000, respectively. Cancellations of scheduled procedures continue to increase based on the severity of the stenosis and the number of major coronary artery stenosis. The degree of stenosis and the number of vascular stenosis were independent predictors of cancelling scheduled surgery.ConclusionsFor patients with thoracic tumors scheduled for non-cardiac surgery, the results suggested by CCTA significantly influenced surgery planning and facilitated to reduce perioperative cardiovascular events.

Clonal Hematopoiesis Is More Common in People Living with HIV and May be Associated with Increased Prevalence of Cardiovascular Disease

Background: Cardiovascular disease (CVD) is more common in people living with HIV (PLWH) and may be related to abnormal immune activation. With aging, the expansion of mutated hematopoietic clones or clonal hematopoiesis (CH) has been associated with CVD events in the general population and is hypothesized to be driven by systemic inflammation. We investigated whether CH was more common in PLWH compared to those without HIV, whether the distribution of CH mutations differed by HIV status, and whether CH was associated with subclinical coronary atherosclerosis in PLWH.Methods: Study participants were selected from men in the Baltimore -Washington DC center of the Multicenter AIDS Cohort Study (MACS) who had had coronary CT angiography (CTA) as part of the MACS Cardiovascular Study 2. The MACS is a prospective study of the natural history of HIV infection in men who have sex with men, and includes both PLWH and HIV-uninfected men. Since the prevalence of CH increases with age, the oldest participants were preferentially included in this study. To detect CH, DNA extracted from viably frozen peripheral blood mononuclear cells or cell pellets was subjected to targeted, error-corrected, ultra-deep next generation sequencing (NGS) which included 70 genes frequently mutated in hematologic malignancies. CTA results and inflammatory biomarker levels were already available from MACS data.Results: The current analysis was a cross-sectional study involving 118 participants: 86 (72.9%) PLWH and 32 (27.1%) HIV-uninfected men (HIV-). The groups were well-balanced in terms of known major risk factors for CH such as age and smoking. The median age was 53 and 54 years for PLWH and HIV- men, respectively (p=0.147). Caucasians represented 37 (43.0%) of PLWH and 21 (65.6%) of HIV- men. Out of 86 PLWH, 72 (83.7%) were on antiretroviral therapy (ART) at the time of the assessment; 41 (47.7%) on a PI-containing regimen and 31 (36.0%) on an NNRTI-containing regimen. The HIV viral load was under 400 copies/mL in 77 (89.5%) of PLWH, and the median (IQR) CD4+ count was 585 (397, 745)/mL. The prevalence of coronary artery stenosis of 50% or more was 12 (14.3%) in PLWH and 5 (16.1%) in HIV- men (p = 0.774).Since the minimum size of the biologically relevant CH is unknown, we applied variant allele frequency (VAF) cut-offs of > 0.5% and > 1%. For both cutoffs, CH was significantly more frequent in PLWH than in HIV- men (p=0.012 and p=0.036, respectively) (Figure 1A). Mutations in epigenetic modifiers (DNMT3A, TET2) were the most common mutations among both PLWH and HIV- men. Interestingly, DNMT3A mutations were more frequent in PLWH (Figure 1B). For both VAF cut-offs, PLWH had significantly more somatic mutations than HIV-uninfected men (p = 0.043 and 0.033, respectively) (Figure 1C).Since inflammation-mediated complications of CH become more apparent in people with larger clones, we focused on CH with VAF > 1% in order to determine the clinical consequences of CH in PLWH. As CH is known to be a risk factor for accelerated CVD in the general population, we asked whether CH was also associated with subclinical atherosclerosis in PLWH. Coronary artery stenosis > 50% (moderate/severe) was significantly more frequent in PLWH with CH compared to PLWH without CH (p = 0.032) (Figure 1 D). This difference remained significant in multivariable logistic regression models that adjusted for the Framingham coronary heart disease 10-year risk (p=0.017) and for the Framingham hard coronary heart disease 10-year risk (p<0.01).Additionally, we examined the association of serum concentrations of several inflammatory markers such as CRP, IL-1b, IL-6, as well as white blood cell count, with the presence of CH in PLWH, but we found no significant associations.Conclusions: CH was more common in PLWH compared to HIV-uninfected men, and PLWH had more somatic mutations. Moreover, the presence of CH was significantly associated with the presence of coronary artery stenosis > 50% (moderate/severe) in PLWH, even after adjusting for known CVD risk factors. The results from our exploratory analysis may provide a potential explanation for increased CVD in PLWH. Larger studies are warranted to further delineate the etiology of increased CH in PLWH and its impact on accelerated CVD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Validation of Coronary Artery Disease Reporting and Data System (CAD-RADS) and Application of Coronary Artery Calcium Data and Reporting System (CAC-DRS) as New Standardized Tools in the Management of Coronary Artery Disease Patients.

Background and ObjectivesThe coronary artery disease reporting and data system (CAD-RADS) is intended to standardize the reporting of CCTA and the subsequent management guidelines of CAD. The present study was conducted to investigate the validation of CAD-RADS and the application of coronary calcium grading in CAD management.Patients and MethodsThe current study is a single-center prospective study that involved 177 participants with chest pain who were submitted to coronary CT angiography (CCTA). Two reviewers independently assessed CCTA results and gave each patient a CAD-RADS category. The reference standard for determining the clinical utility of CAD-RADS was invasive coronary angiography (ICA). The inter-reviewer agreement (IRA) was tested using the intra-class correlation (ICC).ResultsThe study enrolled 111 cases with non-significant CAD and 66 cases with significant CAD based on ICA findings. According to the reviewer, the CAD-RADS had a sensitivity, specificity, and accuracy of 90.9 to 100%, 89.2 to 94.6%, and 93.16 to 93.2%, respectively, for predicting severe CAD. The IRA for CAD-RADS categories was excellent (ICC = 0.960). The best cut-off value for predicting severe CAD was CAD-RADS > 3. Significant relation between Ca and severe CAD (p<0.001) was detected.ConclusionThe current study provides a good understanding of CAD-RADS as a standard tool with high diagnostic accuracy.

High-risk plaque burdens myocardial flow reserve in intermediate coronary artery disease: hybrid analysis of 13N-ammonia PET and coronary CT angiography

Abstract Background 13N-ammonia PET (NH3-PET) can detect myocardial perfusion abnormalities in patients with coronary artery disease (CAD) and also obtain diagnostic quantitative values of absolute myocardial blood flow and myocardial flow reserve (MFR). Low MFR (MFR&amp;lt;2.0) is an independent prognostic factor for major adverse cardiac event in patients with ischemic and non-ischemic heart disease. A feature of low attenuation plaque (LAP) on coronary CT angiography (CCTA) has been known as high-risk plaque (HRP) for acute coronary syndrome even if there is no significant coronary stenosis. The presence of HRP potentially adversely affects MFR, but the hypothesis has not been elucidated. Purpose We aimed to investigate the affect of LAP to MFR in intermediate CAD. Methods One hundred five patients (age 67±9 years, 65% male) with CAD underwent NH3-PET and CCTA within 6 months between April 2015 and March 2019 were enrolled. Based on the results of CCTA, mild and moderate stenosis were defined as 1% to 49% and 50% to 69% stenosis. Ischemic territories for major three vessels were identified by stress/rest NH3-PET images. Finally, 194 coronary arteries with mild to moderate stenosis corresponding to non-ischemic territory were analyzed in this study. LAP was defined as plaques containing CT value less than 90HU. Partially calcified plaques were included in LAP. Entirely calcification plaque without LAP was defined as calcified plaque. MFR for major three vessels were calculated from dynamic scan at stress/rest NH3-PET. Results CCTA showed 80 coronary arteries with LAP (41%), 104 coronary arteries with calcified plaque (54%), 102 vessels with mild stenosis (53%), and 92 vessels with moderate stenosis (47%). MFRs for coronary arteries with LAP were significantly lower than those without LAP (2.1±0.6 vs 2.5±0.6, p&amp;lt;0.0001). The significant difference in MFR between with and without LAP was observed in both mild and moderate stenosis (mild: 2.0±0.6 vs 2.5±0.6, p=0.0015, moderate: 2.1±0.6 vs 2.5±0.6, p&amp;lt;0.0001). In contrast, coronary arteries with calcified plaque had significantly higher MFR than those without (2.5±0.6 vs 2.1±0.6, p&amp;lt;0.0001). In 58 coronary arteries with MFR&amp;lt;2.0, 71% (41/58) had LAP and 24% (14/58) had calcified plaque. In 136 coronary arteries with MFR≥2.0, 29% (39/136) had LAP and 66% (90/136) had calcified plaque. LAP was significantly more frequent in the former and calcified plaque was significantly more frequent in the latter. Conclusion The presence of LAP burdens MFR in mild to moderate CAD. On the other hand, calcified plaque alone had no adverse effect on MFR. LAP is an important sign in CAD risk assessment even without significant coronary stenosis. MFR and stress MPI Funding Acknowledgement Type of funding source: None

THE PLACE OF CARDIAC COMPUTED TOMOGRAPHY IN PREOPERATIVE PLANNING OF EXTENDED SEPTAL MYECTOMY IN PATIENTS WITH OBSTRUCTIVE FORM OF HYPERTROPHIC CARDIOMYOMATHY.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy. Extended septalmyectomy (ESM) is one of the priority methods of treatment of drug-refractory obstructive HCM. In recent years,hospital mortality during surgical correction of obstructive HCM in expert centers does not exceed 1-2 %. However,typical threatening complications of septal myectomy, such as iatrogenic ventricular septal defect (VSD) and rupture of the anterior or posterior walls of the left ventricle (LV), remain a topical issue in surgery of HCM. to show the role of preoperative CT-planning to predict and reduce possible technical problems associated with ESM, including iatrogenic VSD. This study includes 217 symptomatic patients with obstructive HCM, who from April 2016to October 2019 as one of the steps of preoperative planning underwent cardiac CT prior to ESM. Cardiac CT was performed to delineate the left ventricular myocardium, assess the distribution of hypertrophy and the presence ofcrypts. Special attention was also paid to the anatomy of the mitral valve (MV) and subvalvular apparatus. Coronaryartery patency was assessed by CAD-RADS, a standardized method for reporting the results of coronary CT angiography to determine tactics for further management of the patient. In the study group, the average age of patients was (49 ± 15) years, 48 % - men. All patientshad a symptomatic, drug-refractory obstructive form of HCM. The mean maximum wall thickness of the interventricular septum (IVS) was (20 ± 5) mm (range 16-33). The average LV mass was (118 ± 23) g/m2. 195 patients (89.9 %)had systolic anterior motion ( SAM) of the MV. MV and subvalvular apparatus anomalies were detected in 62 patients(28.6 %). A zone of scarring and regression of IVS after alcohol septal ablation (ASA) was detected in 7 patients(0.3 %) with residual LV outflow gradient. Coronary arteries atherosclerosis was detected in 32 patients (14.7 %). Preoperative CT-planning of septal myectomy allows to obtain information on morphology of the LV,IVS, MV and subvalvular apparatus, and gives the surgeon the advantage to form a more accurate plan for the location and volume of septal resection, and avoid complications when correcting obstructive HCM. No iatrogenic VSDwas detected in any of the patient in the study group.

3303Classification of patients with acute chest pain by analytical benchmarks and subsequent management recommendations - A comparison of three highly-sensitivity troponin assays in the ROMICAT trials

Abstract Background Concordance of different highly-sensitive troponin (hsTn) assays in stratifying acute chest pain (ACP) patients according to analytical benchmarks and subsequent emergency department (ED) management recommendations are unknown. Methods We included patients enrolled in the ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography) I and II trials (n=624; 39.1% female; 52.8±10.0 years), who presented to the ED and were referred to further non-invasive diagnostic testing. In ROMICAT I, blood was obtained at 4 hours, and in ROMICAT II at ED presentation, and at 2 and 4 hours and was tested with three state-of-the-art hsTn assays (Roche Diagnostics, Elecsys 2010; Abbott ARCHITECT i2000SR; Siemens Diagnostics, HsVista). In a per sample analysis, we compared the concordance of assays for analytic benchmarks (below the level of detection (LOD)/LOD to 99th percentile/99th percentile to myocardial infarction (&lt;LOD], &gt;&lt;LOD], &gt;MI)/above MI). In a per patient analysis of serial hsTn testing in ROMICAT II, we determined concordance of management recommendations (rule out/observe/rule in) based on 2015ESC guidelines, results of coronary CT angiography and stress myocardial perfusion, and adjudicated endpoints of ACS. Results Overall, only 34.4% (353/1027) of samples were classified into the same benchmark category by all assays (table 1). In a per patient analysis, all assays agreed on the same of management recommendation in 25.3% (49/242) patients after the 1st hsTn, mostly driven by differences in discharge (6.6%, 21.1%, and 61.2%; respectively; all p&lt;0.001). The concordance of management recommendations improved significantly to 67.4% (163/242; p&lt;0.001) after the 2nd hsTn measurement but the final agreement for “observe” and “rule in” remained limited (13/90 and 5/18). Among patients in whom discharge was recommended, at least 18.8% (range: 18.8–21.0% across assays) had a positive imaging/stress test and at least 2.9% (range: 2.9–3.4%) had ACS. Table 1. Classification of measurements from three hsTn assays in 1027 samples of patients with ACP according to analytical benchmarks &lt;LOD LOD – 99th %tile* 99th %tile* – AMI** AMI**&lt; Roche Elecsys, n (%) 578 (56.3) 328 (31.9) 95 (9.3) 26 (2.5) Abbott ARCHITECT, n (%) 176 (17.1) 788 (76.7) 14 (1.7) 49 (4.8) Siemens Vista, n (%) 96 (9.4) 861 (83.9) 33 (3.2) 37 (3.6) *Assay specific 99th percentiles; **as per ESC 2015 guidelines. Conclusion Differences in hsTn assay concordance for analytical benchmarks and subsequent ED management recommendations in patients with ACP are substantial raising concerns about the lack of uniform management. Acknowledgement/Funding Fulbright Visiting Student Researcher Grant

Clinical and radiologic characteristics as well as outcomes of patients with primary cardiac angiosarcoma

Objective: To analyze the clinical, radiologic characteristics, and outcome of consecutive patients with primary cardiac angiosarcoma. Methods: The medical records of patients with primary cardiac angiosarcoma diagnosed through pathology at Peking Union Medical College Hospital between January 2001 and May 2018 were obtained. The results of echocardiography, coronary artery CT angiography (CTA), cardiac magnetic resonance (CMR), positron emission computed tomography (PET-CT), operation, postoperative treatment and prognosis of the patients were analyzed. Results: A total of 16 patients were included, 9 were male, 7 were female, the median age was 42.5 years (31.7, 52.5). The interval from symptoms onset to diagnosis was 4.5 months (0.5-18.0 months). Eight patients were diagnosed at non-metastatic phase, while 8 patients were in metastatic phase. The main complaints were dyspnea, short breath, chest pain, hemoptysis, syncope, edema, fever, fatigue, and cough. Three patients (18.8%) had pericardial tamponade in the course of the disease. Echocardiography was performed on all 16 patients, cardiac mass was found in 12 patients, and pericardial effusion or pericardial thickening was observed in 4 patients. In 8 cases with results of coronary CTA, 5 cases presented signs of right atrium occupation, 1 case presented sign of right ventricle occupation, and 1 case presented isolated massive pericardial effusion. None abnormality was found in 1 case. Of the 7 patients who underwent CMR, 6 presented with right atrium mass occupation and 1 mediastinal mass. Four patients received PET-CT examination and results showed that all presented with hypermetabolic lesions: 2 in right atrium, 1 in pericardium, and 1 in mediastinum, and lung metastasis was found in 2 cases. Among the 16 patients, 13 received surgical treatment, 2 received adjuvant chemotherapy, and 1 received chemotherapy and radiotherapy after biopsy. The median overall survival was 3.0 months. Conclusion: Cardiac angiosarcoma is a rare malignancy with poor prognosis, and echocardiography has only limited diagnostic value for angiosarcoma. CMR, CTA or PET-CT examinations could provide valuable clues for the diagnosis of this rare disease.

Noninvasive detection of coronary vasospastic angina using a double-acquisition coronary CT angiography protocol in the presence and absence of an intravenous nitrate: a pilot study.

To evaluate the feasibility of a double-acquisition coronary CT angiography (CCTA) protocol in the presence and absence of an intravenous (IV) vasodilator infusion for detecting vasospastic angina. Twenty patients with a high clinical probability of vasospastic angina were enrolled. All subjects underwent baseline CCTA without a vasodilator in the early morning followed by a catheterized coronary angiography with ergonovine provocation test. Within 3days, all subjects underwent repeat CCTA during a continuous IV infusion of nitrate. Vasospastic angina as detected by CCTA was defined as significant stenosis (≥50%) with negative remodelling without definite plaques or diffuse small diameter (<2mm) of a major coronary artery with a beaded appearance on baseline CT that completely dilated on IV nitrate CT. The CCTA results were compared to the catheterized ergonovine provocation test as the reference standard. Among 20 patients, the catheterized ergonovine provocation test detected vasospasm in 15 patients. The sensitivity, specificity, positive predictive value and negative predictive value of CCTA in a per-patient-based analysis were 73, 100, 100 and 56%, respectively. Double-acquisition CCTA in the presence and absence of IV infusion of nitrate allows noninvasive detection of vasospastic angina with moderate sensitivity and high specificity. • Limited data exist regarding the efficacy of CCTA in detecting vasospastic angina. • We propose a double-acquisition CCTA protocol with and without IV nitrate injections. • This protocol provides 100% specificity and moderate sensitivity (73%) in spasm detection.

Use of Coronary Computed Tomographic Angiography Findings to Modify Statin and Aspirin Prescription in Patients With Acute Chest Pain

Coronary CT angiography (CCTA) is used in patients with low-intermediate chest pain presenting to the emergency department for its reliability in excluding acute coronary syndrome (ACS). However, its influence on medication modification in this setting is unclear. We sought to determine whether knowledge of CCTA-based coronary artery disease (CAD) was associated with change in statin and aspirin prescription. We used the CCTA arm of the Rule Out Myocardial Infarction using Computed Angiographic Tomography II multicenter, randomized control trial (R-II) and comparison cohort from the observational Rule Out Myocardial Infarction using Computed Angiographic Tomography I cohort (R-I). In R-II, subjects were randomly assigned to CCTA to guide decision making, whereas in R-I patients underwent CCTA with results blinded to caregivers and managed according to standard care. Our final cohort consisted of 277 subjects from R-I and 370 from R-II. ACS rate was similar (6.9% vs 6.2% respectively, p = 0.75). For subjects with CCTA-detected obstructive CAD without ACS, initiation of statin was significantly greater after disclosure of CCTA results (0% in R-I vs 20% in R-II, p = 0.009). Conversely, for subjects without CCTA-detected CAD, aspirin prescription was lower with disclosure of CCTA results (16% in R-I vs 4.8% in R-II, p = 0.001). However, only 68% of subjects in R-II with obstructive CAD were discharged on statin and 65% on aspirin. In conclusion, physician knowledge of CCTA results leads to improved alignment of aspirin and statin with the presence and severity of CAD although still many patients with CCTA-detected CAD are not discharged on aspirin or statin. Our findings suggest opportunity for practice improvement when CCTA is performed in the emergency department.

Relationship between breast arterial calcification on mammography with CT Calcium scoring and coronary CT angiography results.

Background:Mammography as a non invasive method has been suggested to be helpful in predicting coronary artery disease. This study aimed to investigate whether presence and severity of breast artery calcification (BAC) on mammograms is associated with computed tomography coronary angiography (CTCA) finding such as coronary artery calcium (CAC) score and the severity of coronary artery stenosis.Materials and Methods:This cross-sectional study was performed on 150 women aged >40 years who were referred for CTCA. Women who had undergone screening mammography during the first year after CTCA entered the study. CAC score was determined and the severity of coronary artery stenosis was classified into normal, non-significant stenosis, or significant stenosis. Based on the severity of BAC, patients were also grouped into normal, mild, moderate, or severe groups. Then, the correlation between BAC severity and CAC score was determined. Patients with different BAC severity were also compared regarding the relative frequency of different grades of coronary artery stenosis.Results:Mean age of subjects with BAC (n: 35) was significantly higher than patients without BAC (n: 115) (68.03 ± 6.16 versus 54.36 ± 7.63 years, P < 0.0001). Although the relative frequency of different grades of coronary artery stenosis was significantly higher in women with BAC (P < 0.0001), after controlling for age, there was no significant difference between patients with different severity of BAC in the mean of CAC score (P: 0.09). In addition, the correlation between BAC severity and CAC score was not statistically significant (R: 0.09, P: 0.26).Conclusion:We concluded that presence and severity of BAC have no significant correlation with CAC score on CTCA.

Abstract 46: Potential of Coronary CT Angiography to Optimize Medical Therapy in Patients Presenting With Acute Chest Pain

Background: Coronary artery disease (CAD) detected by coronary CT angiography (CCTA) independently predicts cardiovascular events. We assessed the potential of CCTA to tailor aspirin (ASA) and statin medical therapy in acute chest pain patients presenting to the emergency department. Methods: We included all patients from the Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) Trial. This prospective double-blinded observational cohort study included patients presenting with chest pain to the emergency department with low-intermediate risk for acute coronary syndrome (ACS). Patients underwent CCTA prior to admission, followed by standard evaluation. Caretakers were blinded to CCTA results. We assessed medical therapy at presentation and discharge, and determined concordance of CAD status by CCTA with medical therapy dictated by standard care. Results: Complete data on medical therapy was available in 358/368 patients (99%), (53±12 years, 61% men) of whom 7 had a contraindication to ASA and 11 to statin. Standard of care included stress testing in 71% of patients. Prescription of ASA and statins increased from admission to discharge (See Figure). At discharge, 33% of patients without CAD were on ASA and 14% were on statin. Conversely, 46% of patients with nonobstructive CAD by CCTA did not receive ASA and 59% did not receive statin at discharge. Only 66% of patients with obstructive CAD were on statin and ASA at discharge. Based on 2011 American College of Cardiology/American Heart Association secondary prevention guidelines, there was discordance between CAD status by CCTA and medical therapy in 51% of patients. Conclusions: CCTA has great potential to optimize adherence to secondary prevention guidelines in chest pain patients presenting to the emergency department.

Development and Validation of a Predictive Screening Tool for Uninterpretable Coronary CT Angiography Results

Coronary CT angiography (CCTA) is an excellent tool for noninvasive assessment of coronary arteries in low- to intermediate-risk individuals. However, the accuracy of CCTA heavily depends on image quality. Our objective was to develop and validate a tool to predict pre-CCTA risk of obtaining an uninterpretable result in symptomatic patients. Among 8585 symptomatic patients, we identified variables independently associated with the presence of at least 1 uninterpretable major coronary segment to create the uninterpretable risk score (URS). This risk score was developed using both clinical variables and patient variables acquired at the time the CCTA was performed (heart rate and coronary calcium). The URS was then prospectively validated among an additional 915 symptomatic patients. The URS was predictive of uninterpretable results in both the development and the validation cohorts. For every 4-point increase in the URS (range, 0 to 12), the rate of at least 1 uninterpretable coronary segment per 100 CCTA studies increased ≈1.5 fold. Increased heart rate and coronary artery calcium score were predictive of uninterpretable CCTA study results. Uninterpretable results were associated with 3-month outcomes in the development cohort. The URS can categorize patients who are likely to have at least 1 uninterpretable major coronary segment on CCTA. This may aid in appropriate patient selection for CCTA and avoiding radiation exposure in those likely to have an uninterpretable study. Clinical Trial Registration- URL: http:///www.clinicaltrials.gov. Unique identifier: NCT00640068.

Accuracy of coronary artery stenosis detection with CT versus conventional coronary angiography compared with composite findings from both tests as an enhanced reference standard

To prospectively compare the accuracy of coronary CT angiography (CCTA) and conventional coronary angiography (CCA) for stenosis detection using composite findings from both tests as an enhanced reference standard. One hundred thirteen patients underwent CCTA and CCA. Per-segment and per-patient accuracy of CCTA compared with initial CCA interpretation were determined. Angiographers were then unblinded to the CCTA results and re-evaluation of the CCA studies was performed with knowledge of CCTA findings, which was used as an enhanced reference standard to compare the diagnostic accuracy of CCTA versus CCA. When using the enhanced reference standard instead of initial CCA interpretation, CCTA accuracy for identifying segments (patients) with ≥50% stenosis increased from 97.7% (96.5%) to 98.1% (98.2%), sensitivity from 90.5% (100%) to 90.8% (100%), and specificity from 98.4% (94.3%) to 98.9% (97.1%). CCTA identified six segments and two patients with stenoses ≥50% missed on initial CCA interpretation. Compared with the enhanced reference standard the accuracies of CCTA and of initial CCA interpretation were not different (p = 0.87). CCTA compares favourably with CCA for stenosis detection. Use of a composite reference standard combining findings from both tests can control for the effect of false-negative CCA results when evaluating the accuracy of CCTA.

Discordance Between the Morphological and Physiological Information of 64-Slice MSCT Coronary Angiography and Myocardial Perfusion Imaging in Patients With Intermediate to High Probability of Coronary Artery Disease

The aim of this study was to determine the relationship between the morphological and physiological information of coronary CT angiography (CCTA) and stress myocardial perfusion imaging (S-MPI) from the standpoint of risk stratification of patients with intermediate to high probability of coronary artery disease (CAD). In total, 51 patients underwent both CCTA and S-MPI as sequential examinations. In each patient, the severity of coronary plaque and stenosis (>50%) and the presence of myocardial perfusion abnormalities were assessed and the prognostic information from the CCTA and S-MPI results was compared. In 30 patients with normal S-MPI, 3 (10%) had only completely normal coronaries and another 3 (10%) had non-obstructive CAD as observed on CCTA. The remaining 24 patients (80%) with normal S-MPI and all 21 patients with abnormal S-MPI study had obstructive CAD. High-risk CAD (defined as obstructive left main trunk (LMT) lesion or 3-vessel disease) was seen in 10 (33%) of 30 patients with normal S-MPI, although it was less frequent than in the 14 (67%) of 21 patients with abnormal S-MPI. A normal S-MPI result can reflect a wide range of coronary atherosclerosis types and severities and, to some extent, involves severe coronary atherosclerosis such as LMT lesion and 3-vessel disease in patients with an intermediate to high probability of CAD.

Calcified Plaque of Coronary Artery: Factors Influencing Overestimation of Coronary Artery Stenosis on Coronary CT Angiography

Purpose: To assess the influence of calcified plaque characteristics on the overestimation of coronary arterial stenosis on a coronary CT angiography (CCTA). Materials and Methods: The study included 271 coronary arteries with calcified plaques identified by CCTA, and based on 928 coronary arteries from 232 patients who underwent both CCTA and invasive coronary angiography (ICA). Individual coronary arteries were classified into two groups by agreement based on the degree of stenosis from each CCTA and ICA: 1) group A includes patients with concordant CCTA and ICA results and, 2) group B includes patients with an overestimation of CCTA compared to ICA. Parameters including total calcium score, calcium score of an individual coronary artery, calcium burden number of an individual coronary artery, and the density of each calcified plaque (calcium score / number of calcium burden) for each individual coronary artery were compared between the two groups. Results: Of the 271 coronary arteries, 164 (60.5%) were overestimated on CCTA. The left anterior descending artery (LAD) had a significantly low rate of overestimation (47.1%) compared to the other coronary arteries (p=0.001). No significant differences for total calcium score, calcium score of individual coronary artery, and the density of each calcified plaque from individual coronary arteries between two groups was observed. However, a decreasing tendency for the rate of overestimation on CCTA was observed with an increase in calcium burden of individual coronary arteries (p