Significant Concomitant Coronary Artery Disease Research Articles

Abstract 14527: Utility of Routine Invasive Coronary Angiography Prior to Transcatheter Aortic Valve Replacement

Introduction: Despite the high prevalence of CAD in patients with severe aortic stenosis (AS), the optimal management of concomitant coronary artery disease (CAD) before trasncatheter aortic valve replacement (TAVR) remains controversial. Hypothesis: To characterize the contemporary, real-world burden of CAD in contemporary TAVR patients and to evaluate revascularization practices at a high-volume center in the United States. Methods: Analysis of all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant coronary artery disease (stenosis >50%) and subsequent management (medical therapy versus revascularization) were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing and pre-TAVR computed tomography (CT) imaging were all analyzed. Results: A total of 394 patients with severe AS were referred to our institution for TAVR. Thirty-nine patients (9.9%) instead underwent surgical aortic valve replacement (SAVR), of which only 5 (1.3%) underwent SAVR plus coronary artery bypass surgery. Of the remaining 355 patients (77.3 ± 9.3 years old and 59.7% males), 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments and a third underwent ischemia testing prior to PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who ultimately underwent PCI. Conclusions: Only 1 in 25 contemporary TAVR patients had significant CAD and anginal symptoms requiring intervention, questioning the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms and ischemia testing is needed to guide the need, timing and strategy of revascularization. The pre-TAVR CT images could identify significant proximal segment CAD needing PCI.

Usefulness of preoperative coronary computed tomography angiography in high risk non-cardiovascular surgery old patients with unknown or suspected coronary artery disease

BackgroundCumulative evidence has shown that the non-invasive modality of coronary computed tomography angiography (CCTA) has evolved as an alternative to invasive coronary angiography, which can be used to quantify plaque burden and stenosis and identify vulnerable plaque, assisting in diagnosis, prognosis and treatment. With the increasing elderly population, many patients scheduled for non-cardiovascular surgery may have concomitant coronary artery disease (CAD). The aim of this study was to investigate the usefulness of preoperative CCTA to rule out or detect significant CAD in this cohort of patients and the impact of CCTA results to clinical decision-making.Methods841 older patients (age 69.5 ± 5.8 years, 74.6% males) with high risk non-cardiovascular surgery including 771 patients with unknown CAD and 70 patients with suspected CAD who underwent preoperative CCTA were retrospectively enrolled. Multivariate logistic regression analysis was performed to determine predictors of significant CAD and the event of cancelling scheduled surgery in patients with significant CAD.Results677 (80.5%) patients had non-significant CAD and 164 (19.5%) patients had significant CAD. Single-, 2-, and 3- vessel disease was found in 103 (12.2%), 45 (5.4%) and 16 (1.9%) patients, respectively. Multivariate analysis demonstrated that positive ECG analysis and Agatston score were independently associated with significant CAD, and the optimal cutoff of Agatston score was 195.9. The event of cancelling scheduled surgery was increased consistently according to the severity of stenosis and number of obstructive major coronary artery. Multivariate analysis showed that the degree of stenosis was the only independent predictor for cancelling scheduled surgery. In addition, medication using at perioperative period increased consistently according to the severity of stenosis.ConclusionsIn older patients referred for high risk non-cardiovascular surgery, preoperative CCTA was useful to rule out or detect significant CAD and subsequently influence patient disposal. However, it might be unnecessary for patients with negative ECG and low Agatston score.Trial registration Retrospectively registered.

Abstract TP182: Coronary Calcium Score Improves Predictability of Asymptomatic Coronary Artery Disease in Non-embolic Ischemic Stroke Patients

Background and purpose: Many patients with ischemic stroke have concomitant coronary artery disease (CAD). Coronary screening is recommended in patients with high risks for CAD. It remains uncertain which group of stroke patients need evaluation for asymptomatic CAD, and which evaluation tool is appropriate for stroke patients. We investigated whether the coronary artery calcium (CAC) scores could predict significant CAD in patients with acute stroke and which stroke patients need a screening test for significant CAD. Methods: Among consecutive stroke patients between September 2011 and August 2013, a total of 1143 patients who underwent multiple detector CT coronary angiography and cerebral angiography were included. Atherosclerotic stenosis ≥ 50% or obstruction was classified as significant stenosis in coronary and cerebral arteries. Patients were grouped into four subgroups on the basis of CAC score: 0, 0.1-99.9, 100-399.9, and ≥ 400. Presence of hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking were considered as risk factors. Results: Of 1143 patients, significant stenosis was detected in 164 patients (14.3%) in the internal carotid artery (ICA), 279 (24.4%) in the vertebrobasilar artery (VBA), and 81 (7.1%) in the both ICA and VBA. Significant coronary artery stenosis in at least one coronary artery was detected in the 398 patients (34.8%). Two or more risk factors and one or more significant stenosis in the ICA or VBA were considered as screening criteria for choosing potential CAD patients according to AUC analysis. As the CAC score increased, odd ratio for significant CAD remarkably increased (2.1678, CI 1.0152 to 4.6290 for CAC score 0, 5.7193 ,CI 2.9192 to 11.2051 for 0 <CAC score < 100 , 15.6351 ,CI 7.8537 to 31.1262 for 100≤CAC score < 400, and 72.2925, CI 33.8979 to 154.1746 for CAC score≥400, respectively, P <0.05 for all). Conclusion: Two or more risk factors and one or more significant stenosis in the ICA or VBA can be used to choose patients with stroke who need to perform a screening test predicting significant CAD. CAC score also can be used as a screening to perform coronary artery evaluation even in the patients without documented cerebral atherosclerosis.

The Rationale for Performance of CoronaryAngiography and Stenting Before Transcatheter Aortic Valve Replacement: From the Interventional Section Leadership Council of the American College of Cardiology.

Transcatheter aortic valve replacement (TAVR) is an effective, nonsurgical treatment option for patients with severe aortic stenosis. The optimal treatment strategy for treating concomitant coronary artery disease (CAD) has not been tested prospectively in a randomized clinical trial. Nevertheless, it is standard practice in the United States to perform coronary angiography and percutaneous coronary intervention for significant CAD at least 1 month before TAVR. Allexisting clinical trials were designed using this strategy. Therefore, it is wrong to extrapolate current American College of Cardiology/American Heart Association Appropriate Use Criteria against invasive procedures in asymptomatic patients to the TAVR population when evaluating the quality of care by cardiologists or hospitals. In this statement from the Interventional Section Leadership Council of the ACC, it is recommended that percutaneous coronary intervention should be considered in all patients with significant proximal coronary stenosis in major coronary arteries before TAVR, even though the indication is not covered in current guidelines.

Fused cardiac hybrid imaging with coronary computed tomography angiography and positron emission tomography in patients with complex coronary artery anomalies.

To provide data on the value of fused cardiac hybrid imaging with coronary computed tomography angiography (CCTA) and positron emission tomography myocardial perfusion imaging (PET-MPI) in patients with complex coronary artery anomalies (CCAA). This is a retrospective, single-center study. Seven consecutive patients with CCAA (mean 57±7y, 86% were male) who underwent clinically indicated hybrid CCTA/PET-MPI between 2005 and 2015 in our clinic were included. The findings from both modalities and fused cardiac hybrid imaging were evaluated in these patients. Out of the seven patients with CCAA, two patients had Bland-White-Garland anomaly, two patients showed a coronary artery fistula, two patients showed a "single right," and one patient showed a "single left" coronary artery. Semiquantitative fused hybrid CCTA/PET-MPI depicted inferolateral scar matching the territory of a nonanomalous vessel with significant concomitant coronary artery disease (CAD) in one patient only. In contrast, analysis of quantitative myocardial blood flow (MBF) as assessed by fused hybrid CCTA/PET-MPI revealed abnormally reduced flow capacities in the territories subtended by the anomalous vessels in 4 patients. In this case series of middle-aged patients with CCAA, perfusion defects as assessed by semiquantitative PET-MPI were rare and attributable to concomitant CAD rather than to the anomalous vessel itself. By contrast, impaired MBF as assessed by quantitative hybrid CCTA/PET-MPI was revealed in the majority of patients in the vessel territories subtended by the anomalous coronary artery itself. Fused hybrid CCTA/PET-MPI incorporating information on morphology and on semiquantitative and quantitative myocardial perfusions may provide added value for the management of patients with CCAA.

Management of Coronary Artery Disease in Patients With Descending Thoracic Aortic Aneurysms.

The combination of descending aortic aneurysm (DAA) with concomitant coronary artery disease (CAD) is associated with increased morbidity and mortality. We review the surgical management for patients with this combined disease. From January 2000 to January 2014, we performed 268 elective surgeries on the descending or thoracoabdominal aorta. Sixty-six patients (24.7%) had significant CAD. Indications for aortic intervention included thoracoabdominal aortic aneurysm (TAAA) in 28 (42.4%), DAA in 36 (54.5%), and coarctation and ulcer in one each. Fifty-two (78.8%) patients had prior CAD, with remote coronary intervention in 32 (48.5%). Sixteen (24.2%) patients required coronary intervention prior to aortic surgery, percutaneous coronary intervention in three and coronary artery bypass grafting (CABG) in 13 (six off-pump). We used the right internal thoracic artery (ITA) because of vulnerability of the left ITA during DAA clamping; the left ITA as a free graft or in situ when disease was distant to the left subclavian artery; and off-pump CABG to avoid manipulation and embolization. Mean duration between coronary intervention and aortic surgery was 37.2 days. There was no mortality or major adverse cardiac events (MACE) following coronary intervention or during interim to aortic surgery. There were two (3%) cardiac mortalities following DAA/TAAA repair. CAD is common among patients with DAA/TAAA. We recommend aggressive evaluation and prior treatment of CAD to minimize perioperative MACE.

Framingham Risk Score for the prediction of coronary artery disease in patients with chronic rheumatic heart disease.

Patients with chronic rheumatic heart disease (CRHD) have concomitant coronary artery disease (CAD), but the model to detect coexistent coronary artery stenosis prior to surgery has not been validated. Our study investigated whether the Framingham Risk Score (FRS) is a valid predictor of CAD in patients undergoing surgery for CRHD. A total of 989 rheumatic patients were enrolled between 2005 and 2010. They were subdivided into two groups according to coronary angiography (CAG) results to identify potential factors in the development of CAD. Finally, all patients were assessed using the FRS to examine the association between the 10-year cardiovascular disease (CVD) risk and CAD. There were statistically significant inter-group differences in terms of age, sex, smoking, hypertension, bypass surgery and cardiac function in the New York Heart Association (NYHA) classification status (p<0.05). We showed that the FRS had high accuracy in predicting CAD in female and male patients with CRHD. In the male group, the area under the curve (AUC) for predicting CAD was 0.904, with a specificity of 90.3% and sensitivity of 76.1%. In the female group, the AUC for predicting CAD was 0.924, with a specificity of 77.5% and sensitivity of 90.9%, respectively. With a cut-off point of a 10-year CVD risk of 12.5 (%) in the male group and a 10-year CVD risk of 2.5 (%) in the female group, the FRS identified 746 low-risk patients, including 11 (4.3%) with CAD in the male group and 4 (0.8%) with CAD in the female group. None of the patients needed an indication for coronary artery bypass grafting (CABG). The FRS model can accurately predict the prevalence of significant CAD and can reliably identify low-risk patients in whom routine pre-surgical angiography could be avoided.

Non rate-controlled CT coronary angiography for the exclusion of obstructive coronary artery disease in the assessment of patients referred for transcatheter aortic valve implantation

Purpose: Optimal management of concomitant coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is contentious. This study aimed to assess the role of routine non rate-controlled CT coronary angiography (CTCA) in assessing CAD in patients referred for TAVI, thereby potentially precluding the need for invasive coronary angiography (ICA). CTCA in this cohort can be difficult due to the high burden of coronary calcium and the inability to perform standard pharmacological rate control. Methods: All patients underwent an ECG-gated 128-slice calcium score and CT angiogram to assess peripheral vasculature, aortic anatomy, aortic valve calcification and location of the coronary ostia. Coronary artery calcium scores (CACS) and CTCA images were scored by two independent, blinded observers and compared with ICA performed prior to TAVI. Significant coronary stenosis was defined as ≥70% and ICA was deemed the gold standard for true disease status. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated for CTCA at a patient level. Results: 70 consecutive patients referred for consideration of TAVI were studied: 40% male (n=28), mean age 78.9yrs (±7.91), 23% diabetic (n=16). Significant CAD was demonstrated in 30% of ICA studies (1 vessel disease (VD) 20% [n=14], 2VD 8.6% [n=6], 3VD 1.4% [n=1]). The sensitivity, specificity, PPV and NPV of CTCA for the detection of significant coronary stenoses were 57.9% (CI: 33.5% to 79.7%), 87.0% (CI: 75.1% to 94.6%), 61.1% (CI: 35.8% to 82.6%) and 85.4% (CI: 73.3% to 93.5%) respectively. The vast majority of false positive (5/6; 83%) and false negative (6/7; 86%) CTCAs were seen in patients in the highest quartile of CACS (>400). Conclusions: In patients undergoing CT assessment prior to TAVI, non rate-controlled CTCA shows poor sensitivity but good specificity and negative predictive value for the detection of significant CAD. A CAC score >400 may represent a threshold above which invasive angiography is mandated.

Prevalence of coronary artery disease before valvular surgery in patients with rheumatic valvular disease

Although many patients with valvular heart disease have concomitant coronary artery disease (CAD), there are limited data on the association between rheumatic valvular disease (RVD) and CAD. In this study, we aimed to investigate the prevalence of CAD in a group of patients with RVD and undergoing coronary angiography before valvular surgery. In this retrospective analysis, we enrolled a total of 1075 patients (658 women, 61.2%; mean age: 53.2 ± 9.9 years) who underwent coronary angiography for the evaluation of CAD before valvular surgery between January 2003 and May 2010. The overall prevalence of significant CAD was 11.1%. Patients with significant CAD were older than patients without significant CAD (55.16 ± 10.4 vs. 51.45 ± 9.1; P<0.001). In addition, hypertension, smoking, diabetes mellitus, and dyslipidemia were more prevalent among patients with significant CAD (P<0.05). After adjustment for several risk factors, only aortic stenosis remained the predictor of significant CAD (odds ratio: 1.66; 95% confidence interval: 1.26-2.19; P<0.001). However, aortic regurgitation was inversely associated with the presence of CAD (odds ratio: 0.56; 95% confidence interval: 0.21-1.01; P<0.001). The overall prevalence of CAD in our population with RVD was low. Rheumatic aortic stenosis is associated with an increased prevalence of CAD, whereas the prevalence of CAD is lower in those patients with aortic regurgitation.

The Frequency and Risk of Preclinical Coronary Artery Disease Detected Using Multichannel Cardiac Computed Tomography in Patients with Ischemic Stroke

Background: Atherosclerosis is a systemic disease. Many ischemic stroke patients may have concomitant coronary artery disease (CAD). Detection and treatment of preclinical CAD in stroke patients may improve long-term outcome and survival because CAD is a major cause of death during follow-up in stroke patients. However, association between coronary and cerebral artery atherosclerosis in stroke patients has not fully been investigated. This study aimed at examining the frequency and high-risk groups of CAD in ischemic stroke patients. Methods: Consecutive patients who were admitted due to acute ischemic stroke between July 2006 and June 2010 were prospectively enrolled in this study. A total of 1,304 patients who underwent MSCT coronary angiography and cerebral angiography were included in this study. By using 64-multislice computed tomography coronary angiography, we investigated the frequency of CAD and association between coronary and cerebral artery atherosclerosis in terms of location and burden (severity and extent) in stroke patients. We also sought to identify high-risk groups for CAD among stroke patients. Results: The frequency of significant (≧50%) CAD was 32.3% and the frequency of any degree of CAD was 70.1%. Diabetes mellitus, serum levels of total cholesterol, high-density lipoprotein cholesterol and triglyceride, and significant stenosis of the extracranial carotid, intracranial vertebral and basilar arteries were independently associated with CAD. However, no association was found between CAD and significant stenosis of the anterior, middle and posterior cerebral arteries. The association between CAD and cerebral atherosclerosis was stronger with increased severity and extent of cerebral atherosclerosis. When compared to patients with <2 risk factors and without significant cerebral atherosclerosis, those with multiple (≧2) risk factors and atherosclerosis in both the carotid and the vertebrobasilar arteries had very high risks of CAD [odds ratio (OR) 8.36; 95% confidence interval (CI) 4.15–16.87]. The risk was also high in patients with multiple risk factors and atherosclerosis in either the carotid or the vertebrobasilar artery (OR 4.13; 95% CI 2.62–6.51), and in those with <2 risk factors but atherosclerosis in both the carotid and the vertebrobasilar arteries (OR 3.40; 95% CI 1.22–9.47). Conclusions: A substantial portion of stroke patients had preclinical CAD, and there was a clear relationship between coronary and cerebral artery atherosclerosis in terms of location and burden. The risk of CAD was particularly high in stroke patients with multiple risk factors and atherosclerosis of the carotid and/or vertebrobasilar arteries.

Role of Coronary Angiography Before Radiofrequency Ablation in Patients Presenting With Paroxysmal Supraventricular Tachycardia

During episodes of paroxysmal supraventricular tachycardia (PSVT), electrocardiograms frequently show ST-segment depressions, and patients may experience typical chest pain prompting invasive coronary angiography. We evaluated 114 patients presenting with PSVT for concomitant coronary artery disease (CAD). Patients were classified as to the type of PSVT, symptoms during PSVT, and cardiovascular risk factors. Maximum heart rate, extent of ST-segment depression, and cardiac troponin levels during PSVT were recorded. Patients were subjected to exercise testing and/or coronary angiography. During PSVT, symptoms suggestive of myocardial ischemia, including chest pain (31%), ST-segment depression (61%), and elevated troponin levels (12%), were common. Sixty-seven patients (59%) underwent coronary angiography. The overall prevalence of significant CAD was found to be low (4%) and did not correlate to symptoms during tachycardia. Routine coronary angiography cannot be recommended in patients with PSVT unless routine evaluation outside episodes of tachycardia suggests the presence of significant CAD.

The Value of Percutaneous Coronary Intervention in Aortic Valve Stenosis with Coronary Artery Disease

Objectives The study determines whether treatment of coronary disease by percutaneous coronary intervention (PCI) in the presence of severe aortic stenosis (AS) is feasible and defines which patients might benefit most. Background Severe symptomatic AS is considered a class I indication for aortic valve replacement (AVR). Many patients with AS have concomitant coronary artery disease (CAD), and the true reason for symptoms is often unclear. It is common practice to combine AVR with coronary artery bypass grafting. However, in some cases PCI alone might improve symptoms and allow surgery to be deferred. Methods We analyzed 38 consecutive patients who underwent PCI for CAD in the presence of significant AS between 1989 and 2004. Data included demographic factors, clinical features, angiographic, and echocardiographic information. Events during follow-up included PCI complications, improvement post-PCI, AVR, and death. Statistical analysis was used to assess the impact of PCI on outcome and survival. Results The mean age of the study group was 71 ± 9.3 years, and the mean aortic valve area was 0.84 ± 0.28 (0.4–1.2) cm 2. Reasons for choosing PCI over surgery were patients’ preference, high surgical risk, and cardiologist recommendation. Thirty-five patients (92.1%) reported symptomatic improvement after PCI, and no major PCI-related complications were recorded. Significant predictors for long-term event-free survival were good functional class ( P = .006) and single-vessel coronary disease ( P = .017). Conclusion PCI in patients with severe AS and significant CAD is safe, offers relief of symptoms in most cases, and has good long-term outcome in a subset of patients who have mild CAD and good functional class. This therapeutic approach should be considered in such patients and in those with high surgical risk.

Preoperative Exclusion of Significant Coronary Artery Disease by 64-Slice Ct Coronary Angiography in a Patient with a Left Atrial Myxoma

A 49-year-old man without any significant past medical history presented to the emergency department with complaints of diploplia, paresthesias in both arms, vertigo, tinnitus in the right ear, and dysarthria. Physical examination was unremarkable. A computed tomographic (CT) scan of the head was normal. These symptoms resolved within several hours, consistent with a transient ischemic attack. Magnetic resonance imaging of the brain revealed acute infarcts in the left cerebellar hemisphere and in the right occipital lobe, suggesting a thromboembolic source. Transesophageal echocardiography disclosed a 2 × 2-cm mass attached to the left atrial aspect of the atrial septum, and surgical excision was planned. As the patient was considered to have a very low risk for the presence of significant arterial narrowing, he underwent a 64-slice cardiac CT scan rather than invasive coronary angiography. The scan demonstrated minimal plaque in the coronary arteries (Figure ​(Figure11). The left atrial mass was also well visualized on both the axial slices and also with three-dimensional imaging (Figure 2a–c). Subsequently, the patient's left atrial mass was excised without complication, and the mass was a typical myxoma (Figure 2d, e). This case demonstrates how, in the future, routine invasive coronary angiography may not be necessary as part of the workup for noncoronary cardiac surgery. In this instance, significant concomitant coronary artery disease was effectively excluded with multislice CT rather than an invasive procedure, thus allowing the surgery to proceed without a cardiac catheterization. In addition, CT imaging assisted with long-term prognostic information, as it suggested the need for the patient to be on cholesterol reduction therapy by demonstrating the early presence of coronary atherosclerosis. Figure 1 Three-dimensional reconstruction of the patient's coronary arteries (3D) with multislice computed tomography. Curved reformat images of the left anterior descending (LAD) coronary artery, right coronary artery (RCA), and left circumflex coronary artery ... Figure 2 (a, b) Axial slices from the patient's multislice computed tomographic scan demonstrating the myxoma attached to the left atrial aspect of the atrial septum (arrowheads). (c) The myxoma (arrowhead) shown via a “navigator” view inside the ...

Detection of coronary artery disease by dipyridamole thallium tomography in mitral valve stenosis

The severity of mitral valve stenosis (MS) can be reliably estimated by ultrasound methods, 1 but the detection of concomitant coronary artery disease (CAD) is clinically difficult. Previous studies have suggested that exercise thallium scintigraphy is useful in the diagnosis of CAD in patients with valvular heart disease, 2 but there is little information on its value in patients with rheumatic MS. Conventional exercise scintigraphy may have low sensitivity in detecting CAD in patients with critical valve lesions due to the poor exercise tolerance of these patients. We report on the use of dipyridamole thallium tomography in diagnosing angiographically significant CAD in patients with MS.