Significant Coronary Artery Disease In Patients Research Articles

Left atrial functional assessment a prime clue in solving the puzzle of stable angina symptoms in suspected coronary artery disease patients

Abstract Background Assessing clinically for significant coronary artery disease (CAD) in stable angina patients presents a formidable task. Routinely performed echocardiography is limited in diagnosing CAD with provision for the regional wall motion abnormality (RWMA) for left ventricle (LV) systolic dysfunction and altered mitral inflow velocities for LV diastolic dysfunction. However, the advent of two-dimensional (2D) speckle-tracking technique has established the era of strain imaging, opening new possibilities in echocardiography. It is now possible to have a detailed functional assessment of left atrium (LA). We utilised speckle tracking imaging to obtain strain parameters for LA function. Combining these strain parameters with the doppler myocardial velocities and mitral inflow velocities, may prove useful mode of imaging to diagnose significant CAD in stable angina patients. Purpose To study the parameters of left atrial functions utilising echocardiographic strain imaging and evaluate their correlation with the syntax score-II in patients with symptoms of stable angina. Methods 103 patients with symptoms of stable angina undergoing coronary angiography for suspected coronary artery disease(CAD), were considered for LA function assessment and compared with their syntax-II score. Results The LA reservoir function parameters, peak atrial longitudinal strain (PALS) and peak global systolic strain rate (LAsSR), decreased with increasing syntax-II score (p values 0.011 and 0.001 respectively) and the parameter of LA conduit function, peak global early diastolic strain rate (LAeSR) increased (p value <0.001). The LA filling pressures reflected by E/e`, also increased with more severe syntax-II score (p value <0.001). We, further, configured cut off values of < 23.56 for PALS, < 1.15 for LAsSR, > -1.09 for LAeSR, and E/e` ratio > 10.39 as predictors of significant CAD, with good sensitivity and specificity. Therefore, stable angina patients who had significant CAD on coronary angiogram represented by severe syntax score-II, had higher LA filling pressures and deranged LA function with transition from more of reservoir chamber to merely a conduit. Conclusion Our study shows a significant association between LA strain parameters (PALS, LAsSR, and LAeSR) and LA filling pressures (E/e`), with the presence of significant CAD in these patients. The stable angina patients with more severe CAD as quantified by their severe syntax score-II, have an impaired LA reservoir and LA functions more as a conduit, with elevated filling pressures. This study establishes a significant association between LA deformation strain variables and severity of CAD and hence LA strain imaging can be a useful tool to diagnose significant CAD in stable angina patients.

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging.

Coronary artery disease (CAD) is a leading cause of death in developed countries. Non-invasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI. Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography. A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male.Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study (67.99 (95% CI 60.49-75.49) vs. 77.56 months (95% CI 75.14-79.99); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1.15 (68.39 (95% CI 60.69-76.10) vs. 77.31 months (95% ICCI 74.68-79.76); p = 0.013). In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest end-systolic volume ratio ≥ 1.15, during a follow-up period of five years.

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

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

Diagnostic accuracy of stress CMR to evaluate chronic coronary syndromes: an updated meta-analysis

Abstract Background Stress cardiovascular magnetic resonance (CMR) imaging is utilised for the evaluation of patients with stable chest pain and intermediate or high pre-test likelihood of coronary artery disease (CAD). Purpose To provide an updated synthesis of diagnostic accuracy of stress CMR imaging for the diagnosis of anatomically and functionally significant CAD in patients with stable chest pain and suspected or known CAD. Methods After prospective registration and approval of the study protocol, we performed a systematic review and meta-analysis of studies published between 2000 through 2021, enrolling ≥100 patients, and reporting on the diagnostic accuracy of stress CMR imaging to diagnose anatomically and functionally significant CAD with invasive coronary angiography (ICA) or ICA and fractional flow reserve (FFR <0.80) as the reference standard. The novel split component synthesis method was used through the SCSmeta function in R. The meta-analysis yielded pooled diagnostic indicators including diagnostic odds ratio (DOR), sensitivity, specificity, positive likelihood ratio (pLR), negative likelihood ratio (nLR) and area under the curve (AUC). Results We identified a total of 32 studies pooling an overall population of 7,678 individuals (mean age 62 years, 70% males, CAD prevalence 52%). Compared with ICA (29 studies, 7,360 patients), stress CMR yielded a pooled DOR of 19.2 (95% CI: 12.5–29.4), a sensitivity of 84% (95% CI: 79–88%), a specificity of 79% (95% CI: 73–84%), a pLR of 3.9 (95% CI: 3.0–5.3), a nLR of 0.2 (95% CI: 0.2–0.3), and an AUC of 0.81 (95% CI: 0.78–0.84) for the detection of anatomically obstructive CAD. Compared with ICA and FFR (8 studies, 1,196 patients), stress CMR yielded a pooled DOR of 26.4 (95% CI: 10.6–65.9), a sensitivity of 81% (95% CI: 68–89), a specificity of 86% (95% CI: 75–93%), a pLR of 5.8 (95% CI: 3.0–11.4), a nLR of 0.2 (95% CI: 0.1–0.4), and an AUC of 0.84 (0.77–0.89) for the detection of functionally obstructive CAD. Higher diagnostic accuracy was observed for 3 Tesla myocardial perfusion imaging studies to detect both anatomically and functionally obstructive CAD, with pooled DORs of 24.3 and 33.2, respectively. Conclusions In patients with stable chest pain and known or suspected CAD, stress CMR imaging yields high diagnostic accuracy to detect both anatomically and functionally obstructive CAD. Stress CMR perfusion imaging at 3 Tesla is to be associated with overall greater diagnostic accuracy. Funding Acknowledgement Type of funding sources: None.

Functional stress imaging to predict abnormal coronary fractional flow reserve: the PACIFIC 2 study.

AimsThe diagnostic performance of non-invasive imaging in patients with prior coronary artery disease (CAD) has not been tested in prospective head-to-head comparative studies. The aim of this study was to compare the diagnostic performance of qualitative single-photon emission computed tomography (SPECT), quantitative positron emission tomography (PET), and qualitative magnetic resonance imaging (MRI) in patients with a prior myocardial infarction (MI) or percutaneous coronary intervention (PCI).Methods and resultsIn this prospective clinical study, all patients with prior MI and/or PCI and new symptoms of ischaemic CAD underwent 99mTc-tetrofosmin SPECT, [15O]H2O PET, and MRI, followed by invasive coronary angiography with fractional flow reserve (FFR) in all coronary arteries. All modalities were interpreted by core laboratories. Haemodynamically significant CAD was defined by at least one coronary artery with an FFR ≤0.80. Among the 189 enrolled patients, 63% had significant CAD. Sensitivity was 67% (95% confidence interval 58–76%) for SPECT, 81% (72–87%) for PET, and 66% (56–75%) for MRI. Specificity was 61% (48–72%) for SPECT, 65% (53–76%) for PET, and 62% (49–74%) for MRI. Sensitivity of PET was higher than SPECT (P = 0.016) and MRI (P = 0.014), whereas specificity did not differ among the modalities. Diagnostic accuracy for PET (75%, 68–81%) did not statistically differ from SPECT (65%, 58–72%, P = 0.03) and MRI (64%, 57–72%, P = 0.052). Using FFR < 0.75 as a reference, accuracies increased to 69% (SPECT), 79% (PET), and 71% (MRI).ConclusionIn this prospective head-to-head comparative study, SPECT, PET, and MRI did not show a significantly different accuracy for diagnosing FFR defined significant CAD in patients with prior PCI and/or MI. Overall diagnostic performances, however, were discouraging and the additive value of non-invasive imaging in this high-risk population is questionable.

Novel regional longitudinal strain by speckle tracking to detect significant coronary artery disease in patients admitted to the emergency department for chest pain suggestive of acute coronary syndrome

BackgroundGlobal longitudinal strain has shown variable results in detecting ischemia in patients admitted to the emergency department with chest pain, but without other clear evidence of coronary artery disease (CAD). Our aim was to investigate whether assessment of regional longitudinal myocardial function could assist in detecting significant CAD in these patients.MethodsClinical evaluation, electrocardiogram, echocardiogram and troponin T were evaluated in 126 patients admitted with chest pain. A subsequent invasive coronary angiography divided patients into two groups: significant CAD (CAD+) or non-significant CAD (CAD−). Global and regional myocardial function were evaluated by speckle tracking echocardiography. Regional longitudinal strain was defined as the highest longitudinal strain values in four adjacent left ventricular segments and termed 4AS.ResultsCAD+ was found in 37 patients (29%) of which 51% had elevated troponin. Mean 4AS was − 13.1% (± 3.5) in the CAD+ and − 15.2% (± 2.7) (p = 0.002) in the CAD− group. Predictors for CAD+ were age [OR 1.06 (1.01–1.11, p = 0.026)], smoking [OR 3.39 (1.21–9.51, p = 0.020)], troponin [OR 3.32 (1.28–8.60, p = 0.014)) and 4AS (OR 1.24 (1.05–1.46, p = 0.010)]. A cutoff for 4AS of > − 15% showed the best diagnostic performance with event-reclassification of 0.41 (p < 0.001), non-event-reclassification of − 0.34 (p < 0.001) and net reclassification improvement 0.07 (p = 0.60).ConclusionDecreased myocardial function in four adjacent LV segments assessed by strain has the potential to detect significant CAD in patients admitted with chest pain and negative/slightly elevated initial troponin.Trial registration: Current Research information system in Norway (CRISTIN). Id: 555249.

Role of territorial speckle tracking echocardiography in identifying the localization of significant coronary artery disease in patients with non-ST-segment elevation acute coronary syndromes

Abstract Background In non-ST-segment elevation acute coronary syndromes (NSTE-ACS) patients, several studies demonstrated that 2D speckle tracking echocardiography (STE) is able to predict the presence of coronary artery disease (CAD). Conversely, the role of STE for the localization of significant CAD is less well established. Purpose To investigate the role of territorial longitudinal (TLS) and circumferential strain (TCS) assessed with STE as a non-invasive predictor of localization of significant CAD in patients with NSTE-ACS. Methods We retrospectively enrolled NSTE-ACS patients with significant stenosis (≥70%) at least in one major epicardial coronary artery and without previous cardiovascular events over two years of time. Echocardiography was recorded before coronary angiography and myocardial strain was evaluated offline by an operator blinded to clinical data. Territorial strain was calculated grouping and averaging the strain values of the segments perfused by the 3 major coronary arteries. Results 150 patients were included (age 66.3±11.8 years, 71% male; 90.7% NSTEMI and 9.3% unstable angina). ROC curve analysis demonstrated the ability of TLS and TCS to identify the presence of coronary stenosis of LAD, LCX or RCA (AUC for TLS-LAD 0.74 [0.66–0.82] p=0.0001; LCX 0.73 [0.65–0.81] p=0.0001; RCA 0.69 [0.60–0.77] p=0.0001-AUC for TCS-LAD 0.80 [0.70–0.90] p=0.0001; LCX 0.76 [0.67–0.85] p=0.0001; RCA 0.65 [0.55–0.75] p=0.0001), superior to territorial wall motion score index (Figure 1). The diagnostic value was confirmed in the subgroup of patients without wall motion abnormalities for TLS and for TCS, except for RCA. Conclusion Territorial strain assessed with STE might be a non-invasive tool to localize coronary artery stenosis in patients with NSTE-ACS, even without wall motion abnormalities. Funding Acknowledgement Type of funding sources: None. Figure 1. ROC curve analyses

Alternative sites of echocardiographic epicardial fat assessment and coronary artery disease.

Increasing evidence points towards the use of epicardial fat (EF) as a reliable biomarker of coronary artery disease extent and severity. We aim to assess the different locations of echocardiographic EF thickness measurement and their relation with the presence, extent, and severity of coronary artery disease (CAD) in patients admitted with acute coronary syndromes (ACS). Prospective cohort study including patients admitted for ACS. EF was assessed by transthoracic echocardiography and compared with coronary angiography findings. Spearmen correlation analysis was used to search for EF correlations. Receiver-operating characteristic curve analysis was performed to assess the predictive value of the different sites of measurement of EF thickness for the presence of CAD. To evaluate other potential variables independently associated with CAD, we performed multivariate analysis employing logistic regression. 196 patients were included. Significant CAD was diagnosed in 83.7% of patients. In all views, EF thickness was greater in patients with CAD (p < 0.001). We found a moderate correlation between EF thickness and CAD extent and severity. EF thickness measured at RV basal level showed a good performance in predicting significant CAD in patients with ACS (AUC = 0.885, 95% CI 0.80-0.97, p < 0.001). For a value of mean RV basal region EF thickness ≥ 12.57mm, sensitivity was 85% and specificity was 80.8%. In patients admitted with ACS, echocardiographic EF thickness predicted the presence of CAD, as well as its extent and severity. We found EF thickness measured at the RV basal region to be the best predictor of significant CAD.

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

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

Cost-Effectiveness of Cardiovascular Magnetic Resonance in Diagnosing Coronary Artery Disease in the Australian Health Care System

Coronary artery disease (CAD) remains a major public health problem in Australia and globally. A variety of imaging techniques allow for both anatomical and functional assessment of CAD and selection of the optimal investigation pathway is challenging. Cardiovascular magnetic resonance (CMR) is not widely used in Australia, partly due to perceived cost and lack of Federal Government reimbursement compared to the alternative techniques. The aim of this study was to estimate the cost-effectiveness of different diagnostic strategies in identifying significant CAD in patients with chest pain suggestive of angina using the evidence gathered in the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 (CE-MARC trial), analysed from the Australian health care perspective. A decision analytic model coupled with three distinct Markov models allowed eight potential clinical investigation strategies to be considered; combinations of exercise electrocardiogram stress testing (EST), single-photon emission computed tomography (SPECT), stress CMR, and invasive coronary angiography (ICA). Costs were from the Australian health care system in Australian dollars, and outcomes were measured in terms of quality-adjusted life-years. Parameter estimates were derived from the CE-MARC and EUropean trial on Reduction Of cardiac events with Perindopril in patients with stable coronary Artery disease (EUROPA) trials, and from reviews of the published literature. The most cost-effective diagnostic strategy, based on a cost-effectiveness threshold of $45,000 to $75,000 per QALY gained, was EST, followed by stress CMR if the EST was positive or inconclusive, followed by ICA if the stress CMR was positive or inconclusive; this held true in the base case and the majority of scenario analyses. This economic evaluation shows that an investigative strategy of stress CMR if EST is inconclusive or positive is the most cost-effective approach for diagnosing significant coronary disease in chest pain patients within the Australian health care system.

Association between prolonged PR intervals and significant coronary artery disease in patients with non-ST elevation myocardial infarction and unstable angina

Objectives: The purpose of this study was to assess the association between a prolonged PR interval and significant coronary artery disease (CAD) in patients who were acutely admitted with unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI). Background: Prolongation of the electrocardiographic PR interval occurs frequently in clinical practice. Few studies to date have evaluated the association between prolonged PR intervals and significant CAD in hospitalized patients with NSTEMI and unstable angina. Methodology: PR interval was measured in 205 patients with NSTEMI or unstable angina, and the patients were divided into those with normal ( ([0-9]+)200 ms) was present in 96 patients (46.8%). This finding was statistically significantly associated with significant CAD (P = 0.024). In addition, these patients had a trend toward higher Gensini scores (P = 0.093) and a higher frequency of left main coronary artery or three-vessel CAD (P = 0.069). Conclusion: Our study showed that a prolonged PR interval is independently associated with significant CAD in patients with acute coronary syndrome, in contrast with earlier beliefs.

Global Myocardial Work Is Superior to Global Longitudinal Strain to Predict Significant Coronary Artery Disease in Patients With Normal Left Ventricular Function and Wall Motion

Noninvasive detection of functionally significant coronary artery disease (CAD) by echocardiography remains challenging, with the need to perform stress imaging to detect ischemia. The aim of this study was to determine whether global myocardial work (MW), derived from noninvasive left ventricular (LV) pressure-strain loops at rest, can predict significant CAD in patients without regional wall motion abnormalities and preserved LV ejection fraction (EF). One hundred and fifteen patients referred for coronary angiography who had EF≥55%, no resting regional wall motion abnormalities, and no chest pain were assessed using echocardiography. Global MW was derived from noninvasive LV pressure-strain loops constructed from speckle-tracking echocardiography indexed to brachial systolic blood pressure. Global constructive work represented the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation. Global wasted work represented energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation. Global MW efficiency was derived from the percentage ratio of constructive work to the sum of constructive work and wasted work. Patients with significant CAD demonstrated a significantly reduced global MW (P<.001) compared with those without CAD. Global longitudinal strain was significantly reduced (P<.001) in patients with multivessel CAD but not those with single-vessel CAD (P=.47). Receiver operating characteristic curve analysis demonstrated that global MW was the most powerful predictor of significant CAD (area under the curve=0.786) and was superior to global longitudinal strain (area under the curve=0.693). The optimal cutoff global MW value to predict significant CAD was 1,810mm Hg% (sensitivity, 92%; specificity, 51%). Noninvasive global MW derived using LV pressure-strain loops at rest is a more sensitive index than global longitudinal strain to detect significant CAD in patients with no regional wall motion abnormalities and normal EF. This is a potential valuable clinical tool to assist in the early diagnosis of CAD.

Duration of type 2 diabetes mellitus and systolic blood pressure as determinants of severity of coronary stenosis and adverse events in an asymptomatic diabetic population: PROCEED study

BackgroundEvidence from imaging studies suggests a high prevalence of coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM). However, there are no criteria for initiating screening for CAD in this population. The current study investigated whether clinical and demographic characteristics can be used to predict significant CAD in patients with T2DM.MethodsComputed tomography coronary angiography (CTCA) and laboratory assessments were performed in 259 patients diagnosed with T2DM attending clinics in Northwest London, UK. Coronary artery calcium (CAC) was calculated during CTCA. Significant plaque was defined as one causing more than 50% luminal stenosis. Associations between groups and variables were evaluated using Student’s t test, Chi-square tests and univariate and multivariate regression analysis. P < 0.05 was considered statistically significant.ResultsAmong patients with a median duration of T2DM of 13 years and a mean age of 62.0 years, median CAC score was 105.91 Agatston Units. In a multivariate analyses, duration of diabetes, CAC score and the presence and number of coronary artery plaques and presence of significant plaque were significant predictors of cardiovascular adverse events. Systolic blood pressure (SBP) had borderline significance as a predictor of cardiovascular events (p = 0.05). In a receiver operating characteristic curve (ROC) analysis, duration of diabetes of > 10.5 years predicted significant CAD (sensitivity, 75.3%; specificity 48.2%). Area under the ROC curve was 0.67 when combining duration of T2DM > 10.5 years and SBP of > 139 mm Hg. Adverse cardiovascular events after a median follow-up of 22.8 months were also significantly higher in those with duration of T2DM > 10.5 years and SBP > 140 mm Hg (log rank p = 0.02 and 0.009, respectively).ConclusionsRoutine screening for CAD using CTCA should be considered for patients with a diagnosis of T2DM for > 10.5 years and SBP > 140 mm Hg.Trial registration Clinicaltrials.gov identifier: NCT02109835, 10 April 2014 (retrospectively registered)

This Article Corrects: “Coronary Disease in Emergency Department Chest Pain with Recent Negative Stress Testing”

[This corrects the article on p. 384 in vol. 11, PMID: 21079714.].

Development of a multivariate model to predict significant coronary artery disease in Thai patients with left ventricular systolic dysfunction and determine the applicability of coronary angiography: a single-center, retrospective, case–control study

Abstract Background Coronary angiography (CAG) or stress imaging has been performed in almost all Thai patients with left ventricular (LV) systolic dysfunction. If CAG results reveal insignificant coronary stenosis, such patients are diagnosed with nonischemic cardiomyopathy (NICM); however, CAG is considered to provide no benefit and may even harm these patients because it is invasive. Objectives To identify predictors associated with significant coronary artery disease (CAD) (stenosis) in Thai patients with LV systolic dysfunction without angina and without LV regional wall motion abnormality and create a prediction score. Method Retrospective data from patients at a single tertiary-care center with LV systolic dysfunction (LV ejection fraction &lt;50%) diagnosed between August 2000 and October 2014 were separated into a group with ischemic cardiomyopathy (ICM) and a group with NICM according to CAG. Predictors associated with CAD found in normal populations were determined. Multivariate analysis was used to identify predictors associated with significant coronary stenosis in patients with LV systolic dysfunction to develop a model to create a prediction score. Results We included data registered from 240 Thai patients with LV systolic dysfunction. Predictors associated with ICM were age (&gt;60 years), sex (male), and a history of diabetes mellitus (DM). Predictors associated with NICM were body mass index (BMI) &gt;25 kg/m2 and the presence of left bundle branch block (LBBB) on electrocardiography. A simplified equation to predict significant CAD in patients with LV systolic dysfunction is: 3(male sex) + 3(age &gt;60 y) – 5(BMI &gt;25 kg/m2) - 5(LBBB) + 5(DM) - 5. The sensitivity and specificity of this score are 60.5% and 85.1%, respectively. Conclusion Our prediction score has modest sensitivity, but high specificity for predicting significant CAD and can be used to determine who should not undergo CAG.

Diagnostic Accuracy of Coronary Computed Tomography Before Aortic Valve Replacement: Systematic Review and Meta-Analysis.

In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.

Unexpected Cardiac Computed Tomography Findings in Patients With Postoperative Myocardial Injury.

Postoperative myocardial injury (PMI) is a strong predictor of mortality after noncardiac surgery. PMI is believed to be attributable to coronary artery disease (CAD), yet its etiology is largely unclear. We aimed to quantify the prevalence of significant CAD in patients with and without PMI using coronary computed tomography angiography (CCTA). This prospective cohort study included patients of 60 years or older without a history of cardiac disease and with and without PMI after intermediate- to high-risk noncardiac surgery. PMI was defined as any serum troponin I level ≥60 ng/L on the first 3 postoperative days. Main exclusion criteria were known cardiac disease and postoperative ischemic symptoms or electrocardiography abnormalities. Noninvasive imaging consisted of a postoperative CCTA. Main outcome was CAD defined as >50% coronary stenosis on CCTA. The analysis included 66 patients. Median peak troponin levels in the PMI (n = 46) and control group (n = 20) were 150 (interquartile range, 120-298) vs 15 (interquartile range, 10-31) ng/L (P < .01). CAD was found in 23 patients with PMI (50%) vs 3 without PMI (15%; relative risk, 3.3; 95% confidence interval, 1.1-9.8). Remarkably, pulmonary embolism was present in 15 patients with PMI (33%) versus in 4 without PMI (20%; relative risk, 1.6; 95% confidence interval, 0.6-4.3). None of the patients died within 30 days. In patients without a history of cardiac disease, PMI after noncardiac surgery was associated with CAD. In addition, a clinically silent pulmonary embolism was found in one-third of patients with PMI. This urges further research to improve clinical workup using imaging and may have important clinical implications.

A prediction score for significant coronary artery disease in Chinese patients ≥50 years old referred for rheumatic valvular heart disease surgery.

Our goal was to establish a prediction score and protocol for the preoperative prediction of significant coronary artery disease (CAD) in patients with rheumatic valvular heart disease. Using multivariate logistic regression analysis, we validated the model based on 490 patients without a history of myocardial infarction and who underwent preoperative screening coronary angiography. Significant CAD was defined as ≥50% narrowing of the diameter of the lumen of the left main coronary artery or ≥70% narrowing of the diameter of the lumen of the left anterior descending coronary artery, left circumflex artery or right coronary artery. Significant CAD was present in 9.8% of patients. Age, smoking, diabetes mellitus, diastolic blood pressure, low-density lipoprotein cholesterol and ischaemia evident on an electrocardiogram were independently associated with significant CAD and were entered into the multivariate model. According to the logistic regression predictive risk score, preoperative coronary angiography is recommended in (i) postmenopausal women between 50 and 59 years of age with ≥9.1% logistic regression predictive risk score; (ii) postmenopausal women who are ≥60 years old with a logistic regression predictive risk score ≥6.6% and (iii) men ≥50 years old whose logistic regression predictive risk score was ≥2.8%. Based on this predictive model, 246 (50.2%) preoperative coronary angiograms could be safely avoided. The negative predictive value of the model was 98.8% (246 of 249). This model was accurate for the preoperative prediction of significant CAD in patients with rheumatic valvular heart disease. This model must be validated in larger cohorts and various populations.

Myocardial Contrast Echocardiography has Favorable Sensitivity and Specificity for Coronary Artery Disease Diagnosis in Patients with LBBB: A Meta-Analysis

Background: Conflicting evidence exists on the ideal choice of non-invasive pharmacologic stress imaging for coronary artery disease (CAD) diagnosis in patients with left bundle branch block (LBBB). The aim of this meta-analysis is to compare data that examine the sensitivity and specificity of non-invasive pharmacologic stress imaging in patients with LBBB for obstructive CAD diagnosis. Methods: We performed a literature search in MEDLINE, embase.com and Cochrane (CENTRAL) without publication type or language restrictions. Both pharmacologic stress echocardiography (SE) and nuclear myocardial perfusion imaging (MPI) searches were restricted to the period between January 2004 and review time. Exclusion criteria included studies that lacked sensitivity and specificity data. The primary objective was to compare the sensitivities and specificities of all pharmacologic SE, MPI, myocardial contrast echocardiography (MCE), stress cardiac magnetic resonance (CMR) and positron emission tomography (PET) for identifying significant CAD in patients with LBBB. Results: 10 studies met the inclusion criteria for analysis. The sensitivity and specificity odds ratio of MCE was 92% (95% CI 81-97%), 93% (95% CI 86- 97%); Dobutamine (D)-CMR 64% (95% CI 42-82%), 94% (95% CI 85-98%); pharmacologic SE 73% (95% CI 55-86%), 84% (95% CI 75-91%); and pharmacologic MPI 83% (95% CI 72-91%), 56% (95% CI 42-70%). Conclusion: MCE and D-CMR appear to have improved diagnostic accuracy in comparison to pharmacologic SE and MPI in patients with LBBB. Additional MCE and D-CMR studies are warranted given their potential to become the non-invasive gold standard for the diagnosis of CAD in this population.

Dynamic and static tensile mechanical properties of myocardial tissue.

Event Abstract Back to Event Dynamic and static tensile mechanical properties of myocardial tissue. Sherif Ramadan1, 2, 3, Hani Naguib1, 2, 3 and Narinder Paul3, 4 1 University of Toronto, Mechanical and Industrial Engineering, Canada 2 University of Toronto, Smart and Adaptive Polymers Lab, Canada 3 University of Toronto, Institute of Biomaterials and Biomedical Engineering, Canada 4 Toronto General Hospital, Joint Department of Medical Imaging, Canada Introduction: Heart disease is a significant cause of morbidity and mortality that affects 1.3 million Canadians annually[1]. Coronary artery disease (CAD) is a leading cause of heart disease and is due to progressive accumulation of arterial plaque resulting in occlusion of the arterial lumen and abnormal myocardial contractility[2]. Computed Tomography Coronary Angiography (CTCA) is used to exclude significant CAD in patients with low-intermediate pre-test probability[3],[4]. However, dynamic anthropomorphic CT phantom devices that realistically mimic normal and diseased cardiac tissues are required to test new imaging techniques and algorithms that target ultralow radiation dose and high resolution CTCA. This study aims to quantify the mechanical properties of myocardial tissue to allow for the fabrication of phantoms that mimic the behaviour of heart tissue under varying hemodynamic conditions. Materials and Methods: The elasticity of myocardial tissue was tested under static and dynamic conditions. Tensile testing was performed to obtain the Young’s modulus and a dynamic mechanical analyzer (DMA) induced a frequency sweep to determine the complex (dynamic) modulus. A frequency range of 0.5Hz to 3.5Hz was analyzed as these frequencies correspond to human heart rates of 30 to 210bpm. Multiple tissue samples were taken from each pig and lamb heart, these animal models were chosen as they are close human analogues and are commonly used as replacements for human tissue[5],[6].The heart tissue was tested while freshly sacrificed without any intervening freeze-thaw cycles to ensure the integrity of the muscle tissue. The tissue was placed in a balanced salt solution and tested at 37°C to simulate in vitro conditions[7]. Results and Discussion: Preliminary data (mean ± SD): The tensile and complex moduli were tested on 6 pig and lamb hearts; tensile modulus of lamb = 0.06 ±0.03 (n=15 samples) and for pig =0.04 ± 0.03 (n=11 samples); the complex modulus for lamb = 0.03Mpa at 0.5Hz to 0.06 Mpa at 3.5Hz ± 0.02 (n=15 samples) and for pig = 0.03Mpa at 0.5Hz to 0.06 Mpa at 3.5Hz ± .01 (n=15 samples) and both exhibited a linear trend. These values indicate that myocardial tissue behaves similarly to soft rubbers and stiffens under higher frequency loads. Moreover, for tensile testing there was no statistical difference between individual hearts or animals (P values of 0.235, 0.483, and 0.73 between the animals, pig hearts, and lamb hearts respectively). Conclusions: The static and dynamic moduli of myocardial tissue in pig and lamb hearts is between 0.02 and 0.1Mpa which is similar to soft, rubber-like materials. This quantitative data will inform selection and fabrication of customized biomaterials for construction of the myocardium in a dynamic anthropomorphic tissue realistic heart phantom.