Significant Coronary Stenosis In Patients Research Articles

Computed tomography perfusion or fractional flow reserve–computed tomography to assess the significance of stenosis: Literature review

Abstract Detection of myocardial ischemia based on detection and grading of myocardial perfusion is a cornerstone of coronary artery disease (CAD) diagnosis. Coronary CT angiography (CCTA) is a recognized imaging test for exclusion of anatomically significant coronary stenosis in patients with low or moderate probability of CAD, but gives no information on its physiological significance. The two major approaches to evaluate the presence of induced myocardial ischemia using CT, static or dynamic perfusion CT (CTP) or non-invasive fractional flow reserve analysis (FFRCT), have been validated in multiple single- and multi-center studies with comparable results of high sensitivity, specificity and accuracy. Several studies with head-to-head comparison of CTP and FFRCT using invasive FFR measurement as a reference standard showed a slight superiority of CTP, especially in groups of patients with the borderline values of FFR-CT. The principle of myocardial perfusion assessment with CTP looks more physiological than computation models used in FFR-CT. However, the best results were shown by combined use of CCTA, CTP and FFRCT, providing the integrated anatomical and physiological information. Technical advances in CT technique, artificial intelligence and machine learning, together with accumulation of new clinical evidence, will result in development of the best strategy for comprehensive assessment of both coronary anatomy and myocardial perfusion with help of cardiac CT.

Introducing the original web score calculator GARDENIA risk score for severe coronary artery (re)stenosis

Abstract Background/Introduction There are a large number of scores that are used for cardiovascular risk assessment and different online calculators are used to perform it. Risk prediction models provide risk estimates that can assist our decision making and improve guiding for individual clinical outcomes and personalized preventive care. Purpose GARDENIA score is designed to predict highly suspicious probability of significant coronary stenosis in patients without proven CAD or those who have already been revascularized. Methods GAR²DE²NIA is an acronym that incorporates following parameters : Gender, Age, Renal impairment, Respiratory disease, Diabetes Melittus, Echo abnormalities, ECG abnormalities, New symptoms, Ischaemia, Atrial fibrillation. The pointing scale was formed (-1 to 2) on the personal interpretation of evidence based data and is applied and designed as web calculator. The established cut-off values for the risk of significant coronary stenosis is 4. For values below 4, the probability of significant CAD is low, below 0 is very low, equal or greater than 4 significant CAD is high and above 8 is very high. Results Standard statistical formulas for sensitivity, specificity, PPN and NPV were used ( sensitivity 91,43%, specificity 73,33%, PPV 88,89, NPV 78,57). Estimated pilot sample size of 100 patients, was tested on patients cohort treated at the Institute for Cardiovascular Disease Dedinje in the year of 2022. Conclusion This original score is to be checked throughout everyday clinical practice. It is easy to use. It can help in decision making in risk stratification and further treatment of the patients who has never been to cardiologist before, those who has already been revascularized and are symptomatic again or need any kind of non cardiac surgery and the patients we have doubts about what to do next.GARDENIA score calculator

Non-contrast CT-based radiomics nomogram of pericoronary adipose tissue for predicting haemodynamically significant coronary stenosis in patients with type 2 diabetes

BackgroundType 2 diabetes mellitus (T2DM) patients have a higher incidence of coronary artery disease than the general population. The aim of this study was to develop a radiomics nomogram of pericoronary adipose tissue (PCAT) based on non-contrast CT to predict haemodynamically significant coronary stenosis in T2DM patients.MethodsThe study enrolled 215 T2DM patients who underwent non-contrast CT and coronary computed tomography angiography (CCTA). CCTA derived fractional flow reserve (FFRCT) ≤ 0.80 was defined as hemodynamically significant stenosis.1691 radiomics features were extracted from PCAT on non-contrast CT. Minimum redundancy maximum relevance (mRMR) and least absolute shrinkage and selection operator (LASSO) were used to select useful radiomics features to construct Radscore. Logistic regression was applied to select significant factors among Radscore, fat attenuation index (FAI) and coronary artery calcium score (CACS) to construct radiomics nomogram.ResultsRadscore [odds ratio (OR) = 2.84; P < 0.001] and CACS (OR = 1.00; P = 0.023) were identified as independent predictors to construct the radiomics nomogram. The radiomics nomogram showed excellent performance [training cohort: area under the curve (AUC) = 0.81; 95% CI: 0.76–0.86; validation cohort: AUC = 0.83; 95%CI: 0.76–0.90] to predict haemodynamically significant coronary stenosis in patients with T2DM. Decision curve analysis demonstrated high clinical value of the radiomics nomogram.ConclusionThe non-contrast CT-based radiomics nomogram of PCAT could effectively predict haemodynamically significant coronary stenosis in patients with T2DM, which might be a potential noninvasive tool for screening of high-risk patients.

Diagnostic potential of myocardial early systolic lengthening for patients with suspected non-ST-segment elevation acute coronary syndrome

BackgroundDuring early systole, ischemic myocardium with reduced active force experiences early systolic lengthening (ESL). This study aimed to explore the diagnostic potential of myocardial ESL in suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with normal wall motion and left ventricular ejection fraction (LVEF).MethodsOverall, 195 suspected NSTE-ACS patients with normal wall motion and LVEF, who underwent speckle tracking echocardiography (STE) before coronary angiography, were included in this study. Patients were stratified into the coronary artery disease (CAD) group when there was ≥ 50% stenosis in at least one major coronary artery. The CAD patients were further stratified into the significant (≥ 70% reduction of vessel diameter) stenosis group or the nonsignificant stenosis group. Myocardial strain parameters, including global longitudinal strain (GLS), duration of early systolic lengthening (DESL), early systolic index (ESI), and post-systolic index (PSI), were analyzed using STE and compared between groups. Receiver operating characteristic curve (ROC) analysis was performed to determine the diagnostic accuracy. Logistic regression analysis was conducted to establish the independent and incremental determinants for the presence of significant coronary stenosis.ResultsThe DESL and ESI values were higher in patients with CAD than those without CAD. In addition, CAD patients with significant coronary stenosis had higher DESL and ESI than those without significant coronary stenosis. The ROC analysis revealed that ESI was superior to PSI for identifying patients with CAD, and further superior to GLS and PSI for predicting significant coronary stenosis. Moreover, ESI could independently and incrementally predict significant coronary stenosis in patients with CAD.ConclusionsThe myocardial ESI is of great value for the diagnosis and risk stratification of clinically suspected NSTE-ACS patients with normal LVEF and wall motion.

Gar²De²Nia Risk Score as a New Scoring for Severe Coronary Artery Restenosis and It’s Introducing as a Web Score CalculatorPilot Study

Objectives: Gar²De²Nia score is designed to predict highly suspicious probability of significant coronary stenosis in patients without proven CAD or those who have already been revascularized. Background: There are a large number of scores that are used for cardiovascular risk assessment and different online calculators are used to perform it. Risk prediction models provide risk estimates that can assist our decision making and improve guiding for individual clinical outcomes and personalized preventive care. Methodology: Gar²De²Nia is an acronym that incorporates following parameters: Gender, Age, Renal impairement, Respiratory disease, Diabetes Melittus, Echo abnormalities, ECG abnormalities, new symptoms, Ischaemia, Atrial fibrillation. The pointing scale was formed (-1 to 2) on the personal interpretation of evidence based data and is applied and designed as web calculator. The established cut-off values for the risk of significant coronary stenosis are 4. For values below 4, the probability of significant CAD is low, below 0 is very low, equal or greater than 4 significant CAD is high and above 8 is very high. https://www.gardenia.estavela.in.rs Results: Standard statistical formulas for sensitivity, specificity, PPN and NPV were used (sensitivity 91, 43%, specificity 73, 33%, PPV 88, 89, NPV 78, 57). Estimated pilot sample size of 100 patients, was tested on patients cohort treated at the Institute for Cardiovascular Disease Dedinje in the year of 2022. Conclusion: This original score is to be checked throughout everyday clinical practice. It is easy to use. It can help in decision making in risk stratification and further treatment of the patients who has never been to cardiologist before, those who has already been revascularized and are symptomatic again or need any kind of non-cardiac surgery and the patients we have doubts about what to do next.

Diagnostic accuracy of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) in patients before liver transplantation using CT-FFR machine learning algorithm

ObjectivesLiver transplantation (LT) is associated with high stress on the cardiovascular system. Ruling out coronary artery disease (CAD) is an important part of evaluation for LT. The aim of our study was to assess whether CT-derived fractional flow reserve (CT-FFR) allows for differentiation of hemodynamically significant and non-significant coronary stenosis in patients evaluated for LT.MethodsIn total, 201 patients undergoing LT evaluation were included in the study. The patients received coronary computed tomography angiography (CCTA) to rule out CAD and invasive coronary angiography (ICA) to further evaluate coronary lesions found in CCTA if a significant (≥ 50 % on CCTA) stenosis was suspected. CT-FFR was computed from CCTA datasets using a machine learning–based algorithm and compared to ICA as a standard of reference. Coronary lesions with CT-FFR ≤ 0.80 were defined as hemodynamically significant.ResultsIn 127 of 201 patients (63%), an obstructive CAD was ruled out by CCTA. In the remaining 74 patients (37%), at least one significant stenosis was suspected in CCTA. Compared to ICA, sensitivity, specificity, PPV, and NPV of the CT-FFR measurements were 71% (49–92%), 90% (82–98%), 67% (45–88%), and 91% (84–99%), respectively. The diagnostic accuracy was 85% (85–86%). In 69% of cases (52 of 75 lesions), additional analysis by CT-FFR correctly excluded the hemodynamic significance of the stenosis.ConclusionsMachine learning–based CT-FFR seems to be a very promising noninvasive approach for exclusion of hemodynamic significant coronary stenoses in patients undergoing evaluation for LT and could help to reduce the rate of invasive coronary angiography in this high-risk population.Key Points• Machine learning–based computed tomography-derived fractional flow reserve (CT-FFR) seems to be a very promising noninvasive approach for exclusion of hemodynamic significance of coronary stenoses in patients undergoing evaluation for liver transplantation and could help to reduce the rate of invasive coronary angiography in this high-risk population.

The change in high-sensitivity troponin-T as a risk factor for significant coronary stenosis in patients with acute coronary syndrome.

Background/AimsHigh-sensitivity cardiac troponin (hs-TnT) assays detect very low levels of cardiac troponin. This study examined the interval change between initial and subsequent hs-TnT levels and evaluated its ability to predict significant coronary stenosis.MethodsThe study analyzed 163 patients who presented with acute coronary syndrome (ACS) and underwent coronary angiography (CAG) between April 2014 and May 2018. The 0 and 3-hour hs-TnT were checked. The patients were subdivided into positive (n = 32) and negative (n = 131) interval change groups. The presence of significant coronary artery stenosis on CAG in the two groups was compared.ResultsThe positive interval change group was older and had higher 0 and 3-hour hs-TnT and blood glucose levels than the negative interval change group. Significant coronary stenosis was more common in the positive interval change group than in the negative interval change group (68.8% vs. 23.7%, p = 0.001). However, vasospasm was more common in the negative interval change group (6.3% vs. 31.3%, p = 0.003). The positive interval change group had higher rates of bifurcation lesions and received more percutaneous coronary intervention. In multivariate analysis, age, interval change of serial hs-TnT and diabetes mellitus were independent predictors of significant coronary artery stenosis.ConclusionsThis study identified a relationship between the serial change in cardiac biomarkers and the presence of significant coronary stenosis in patients with ACS. Serial hs-TnT change was associated with real angiographic stenosis in patients with ACS.

Pericardial adiposity versus body adiposity measured by BMI in the assessment of coronary atherosclerosis burden in patients with hypertension

ABSTRACT Objectives The link between obesity and hypertension with coronary atherosclerosis is complex. We aimed to assess the association of cardiac fat deposition measured by pericardial fat volume(PFV) using by multi-detector CT(MDCT) and general obesity measured by BMI with subclinical coronary atherosclerotic markers (coronary artery calcium score (CAC), coronary plaque and stenosis) in patients with hypertension and suspected coronary artery disease. Methods Among 496 patients presenting with chest pain who underwent 64-slice MDCT angiography to exclude occlusive coronary disease, 261 patients with hypertension (age: 57 ± 8 years, 45% males) enrolled in the present study. Results PFV showed a significant association with CAC(r = 0.2,P = .001),coronary stenosis severity(PFV median(IQR) 88(63–161) in patients with coronary stenosis<50% compared to PFV median(IQR) 125(85–140) in patients with coronary stenosis ≥ 50%, P = .001) and coronary plaque presence (PFV median (IQR) 89(65–128) in patients without plaque compared to PFV median (IQR) 115(74–150) in patients with plaque presence = 0.03).the significant association of PFV with CAC[odds ratio(95% confidence interval = 0.5(0.19–0.97),P = .001] and coronary stenosis severity [odds ratio(95% confidence interval = 1.1(1.00–1.01),P = .01]persisted after adjustment for conventional cardiac risk. BMI showed a significant association with significant coronary stenosis presence (P = .02).The association of BMI with significant coronary stenosis presence after adjustment for conventional cardiac risk factors (P = .03).BMI showed no significant association with CAC and coronary plaque presence (P > .05). Conclusion PFV showed a significant independent association with coronary calcification and significant coronary stenosis in patients with hypertension rather than BMI.

Comparing the effects of different management strategies on long-term outcomes for significant coronary stenosis in patients with Takayasu arteritis

BackgroundThe long-term outcomes and optimal treatment strategy for patients with Takayasu arteritis (TA) and significant coronary stenosis remain unclear. We aim to investigate the prognosis of these patients according to the initial management strategy. MethodsA total of 57 consecutive patients with TA and significant coronary stenosis were included between 2002 and 2018. The cohort was divided into the percutaneous coronary intervention (PCI) group (n = 18), coronary artery bypass graft (CABG) group (n = 10), and medical-therapy group (n = 29). The primary outcome was major adverse cardiac events (MACEs) defined as a composite of cardiac death, myocardial infarction, and coronary revascularization. ResultsOver a median follow-up of 4.5 (IQR 3.5–8.0) years, 24 (42.1%) patients experienced at least one MACE. The long-term rates of MACEs and re-revascularization were significantly higher in the PCI group than in the other 2 groups (HR 5.306, 95% CI 2.160–13.036, p < 0.001; HR 12.286, 95% CI 3.257–46.343, p < 0.001, respectively). The cumulative incidences of MACEs and subsequent revascularization were similar between the CABG and medical-therapy group. Active disease at baseline and PCI were independent predictors of MACEs (HR, 7.039, 95% CI 2.031–24.396; p = 0.002; HR, 4.400; 95% CI 1.804–10.727; p = 0.001, respectively) and revascularization (HR 4.632, 95% CI 1.010–21.235, p = 0.048; HR 9.820, 95% CI 2.641–36.514, p = 0.001, respectively). ConclusionsThe initial baseline active disease is an important predictor of long-term outcome and subsequent revascularization in patients with TA and significant coronary artery stenosis. Also, PCI is independently associated with higher risk of MACEs and re-revascularization.

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.

CT myocardial perfusion imaging: current status and future perspectives.

Computed tomography myocardial perfusion (CTP) combined with coronary computed tomography angiography (CCTA) may constitute a "1-stop shop" for the noninvasive diagnosis of hemodynamically significant coronary stenosis during a single CT examination. CTP shows high diagnostic performance and provides incremental value over CCTA for the detection of hemodynamically significant coronary stenosis in patients with a high Agatston calcium score or coronary artery stents. Future studies should determine the optimal protocol and clinical value of CTP for guiding revascularization strategy and prognostication. In this article, we review the current status and future perspectives of CTP, focusing on technical considerations, clinical applications, and future research topics.

Noninvasive assessment of coronary blood flow by transthoracic Doppler echocardiography: basic to practical use in the emergency room.

Echo Doppler is widely available in the clinical setting, and the feasibility of coronary flow detection in the left anterior descending coronary artery has been reported as >90% with the use of a high-frequency transducer. Coronary flow detection takes only a few minutes by skilled echocardiologists, and this noninvasive technique can provide useful physiological information in patients with various types of coronary artery disease. Coronary flow velocity reserve measurement by echo Doppler is a simple and easy technique. It is available in the echo laboratory as well as in the outpatient clinic, and can be used as an alternative examination to screen for significant coronary stenosis in patients with stable angina. Moreover, physiological information provided by coronary flow velocity reserve can be used in combination with other imaging modalities that can provide anatomical information of the coronary arteries such as coronary computed tomography or coronary angiography. Coronary flow velocity in patients with acute coronary syndrome (ACS) enables rapid noninvasive differentiation of TIMI-III from TIMI-II coronary reperfusion before emergency coronary intervention. Transthoracic coronary flow detection by echo Doppler contributes to the assessment of the coronary reperfusion status in the emergency room for patients with ACS, prior to invasive coronary angiography.

Association of β-Adrenergic Receptor Gene Polymorphisms With Acute Coronary Syndrome and Cardiovascular Risk Factors in an Arab Population.

We evaluated the association between beta-adrenergic receptor genes (ADRB1 and ADRB2) polymorphism, cardiovascular risk, and acute coronary syndrome (ACS) in individuals from an Arab ethnicity. A total of 388 Qatari participants were assessed and genotyped for ADRB1 (rs1801252 & rs1801253) and ADRB2 (rs1042718 & rs1042713) polymorphisms using allele-specific PCR. Minor allele frequencies (MAF) in each single-nucleotide polymorphisms (SNPs) did not show statistically significant difference between cases and controls. A higher proportion of patients with ACS had homozygous minor alleles (GG) for rs1801253 (28.8% vs 17.1%; P = .019) compared with controls. Among cases with ACS, there was an association of minor allele frequency (G) for rs1801253 with severe coronary artery stenosis (0.485 vs 0.428; P = .04) than that of insignificant stenosis (<50% stenosis). There was a 3-fold increased risk of significant coronary stenosis in patients with diabetes mellitus (DM) and carrier of rs1801253 genotypes with dominant model (P = .01) and recessive model (P = .05). There is a possible synergic association between DM, carrier of ADRB1 (Arg389Gly) variants, and significant coronary artery stenosis among Arabs. Further prospective studies with larger sample sizes are warranted to support our findings.

Troponin I Assay for Identification of a Significant Coronary Stenosis in Patients with Suspected Acute Myocardial Infarction and Wide QRS Complex

BackgroundCommon ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. A large proportion of these patients do not suffer from an AMI, whereas those with ST-elevation myocardial infarction (STEMI) equivalent AMI benefit from an aggressive treatment. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI.MethodsIn 417 out of 1818 patients presenting consecutively between 01/2007 and 12/2008 in a prospective multicenter observational study with suspected AMI a prolonged QRS duration was observed. Of these, n = 117 showed significant obstructive coronary artery disease (CAD) used as diagnostic outcome variable. cTnI was determined at admission.ResultsPatients with significant CAD had higher cTnI levels compared to individuals without (median 250ng/L vs. 11ng/L; p<0.01). To identify patients needing a coronary intervention, cTnI yielded an area under the receiver operator characteristics curve of 0.849. Optimized cut-offs with respect to a sensitivity driven rule-out and specificity driven rule-in strategy were established (40ng/L/96ng/L). Application of the specificity optimized cut-off value led to a positive predictive value of 71% compared to 59% if using the 99th percentile cut-off. The sensitivity optimized cut-off value was associated with a negative predictive value of 93% compared to 89% provided by application of the 99th percentile threshold.ConclusioncTnI determined in hemodynamically stable patients with suspected AMI and wide QRS complex using optimized diagnostic thresholds improves rule-in and rule-out with respect to presence of a significant obstructive CAD.

Abstract 18146: Stress Speckle Tracking Imaging Parameters of Circumferential Deformation in Assesssing Ischemia for Patients With Moderate and High Probability of Coronary Artery Disease

Introduction: Value of longitudinal strain and strain rate (SR) at rest and low dobutamine doses has been shown in small studies however little is known about circumferential strain, circumferential systolic and diastolic SR importance in early stages of dobutamine speckle tracking echocardiography (STE). Hypothesis: Hypothesis that circumferential strain, circumferential systolic and diastolic SR in early stages of dobutamine STE are markers of significant coronary stenosis in patients with moderate and high probability of coronary artery disease (CAD) was assessed. Methods: Dobutamine stress echocardiography and adenosine magnetic resonance imaging were perfomed to 101 patients with moderate and high probability of CAD. CAD was defined as ≥50% diameter stenosis on coronary angiography validated as hemodynamically significant by adenosine magnetic resonance. Patients were divided into two groups based on coronary angiography results: CAD (-) n=57 (56,44%) vs CAD (+) n=44 (43,56%). Circumferential strain, circumeferential systolic and early diastolic SR parameters at rest, low and high dobutamine doses were analysed using 2D STE. Results and Conclusions: There were no significant differences of clinical characteristics, conventional echocardiography and deformation parameters between the groups at rest. All analysed STE parameters at low dobutamine doses were significantly lower in patients wtih CAD (circumferential strain 23,84±7,25% vs 17,98±4,06%, p=0,01, circumferential systolic SR 2,70±0,74 s–1 vs 1,76±0,75 s–1, p=0,002; circumferential early diastolic SR 2,71±0,74 s–1 vs 1,76±0,75 s–1, p=0,002). Logistic regression analysis revealed that STE parameters at low dobutamine doses have significant predictive value for haemodinamically significant coronary stenoses. Circumferential strain, systolic and early diastolic SR obtained at low dobutamine doses are sensitive and specific markers of haemodynamically significant CAD.

Accuracy of multidetector computed tomography for detection of coronary artery stenosis in acute coronary syndrome compared with stable coronary disease: A CORE64 multicenter trial substudy

BackgroundMulti-detector computed tomography angiography (MDCTA) is a promising method for risk assessment of patients with acute chest pain. However, its diagnostic performance in higher-risk patients has not been investigated in a large international multicenter trial. Therefore, in the present study we sought to estimate the diagnostic accuracy of MDCTA to detect significant coronary stenosis in patients with acute coronary syndrome (ACS). MethodsPatients included in the CORE64 study were categorized as suspected-ACS or non-ACS based on clinical data. A 64-row coronary MDCTA was performed before invasive coronary angiography (ICA) and both exams were evaluated by blinded, independent core laboratories. ResultsFrom 371 patients included, 94 were categorized as suspected ACS and 277 as non-ACS. Patient-based analysis showed an area under the receiver-operating-characteristic curve (AUC) for detecting ≥50% coronary stenosis of 0.95 (95% CI: 0.88–0.98) in ACS and 0.92 (95% CI: 0.88–0.95) in non-ACS group (P=0.29). The sensitivity, specificity, positive and negative predictive values of MDCTA were 0.90(0.80–0.96), 0.88(0.70–0.98), 0.95(0.87–0.99) and 0.77(0.58–0.90) in suspected ACS patients and 0.87(0.81–0.92), 0.86(0.79–0.92), 0.91(0.85–0.95) and 0.82(0.74–0.89) in non-ACS patients (P NS for all comparisons). The mean calcium scores (CS) were 282±449 in suspected ACS and 435±668 in non-ACS group. The accuracy of CS to detect significant coronary stenosis was only moderate and the absence or minimal coronary artery calcification could not exclude the presence of significant coronary stenosis, particularly in ACS patients. ConclusionsThe diagnostic accuracy of MDCTA to detect significant coronary stenosis is high and comparable for both ACS and non-ACS patients.

Diagnostic Performance of Algorithm for Computer-Assisted Detection of Significant Coronary Artery Disease in Patients With Acute Chest Pain: Comparison With Invasive Coronary Angiography

The purpose of this study was to evaluate the performance of an automated computer-assisted detection (CAD) algorithm to detect coronary artery stenosis on coronary CT angiography (CTA). We investigated 128 consecutive patients (76 men, 52 women; mean [SD] age, 64 ± 11 years) who had acute chest pain and underwent 128-slice dual-source coronary CTA and invasive coronary angiography at an emergency department. All coronary CTA data were analyzed using customized software for the detection of coronary artery stenosis without human interaction. The diagnostic performance of a CAD algorithm for evaluation of stenosis of at least 50% of vessel diameter was compared with that of human interpretation of coronary CTA, with invasive coronary angiography as a reference standard. Of the 128 patients, 25 patients were excluded because of failure of data processing (n = 9) or history of stent insertion or coronary artery bypass graft (n = 16). Invasive coronary angiography revealed significant stenosis in 62% (64/103) of the remaining patients. In detecting significant stenosis, the CAD algorithm yielded 100% sensitivity, 23.1% specificity, 68.1% positive predictive value (PPV), and 100% negative predictive value (NPV) in per-patient analysis. On per-vessel analysis, the CAD algorithm yielded 90.0% sensitivity, 62.4% specificity, 40.1% PPV, and 95.7% NPV. Human interpretation of coronary CTA yielded 98.4% and 96.7% sensitivities, 79.5% and 95.0% specificities, 88.7% and 84.5% PPVs, and 96.9% and 99.0% NPVs for diagnosing significant stenosis on per-patient and per-vessel analyses, respectively. The CAD algorithm yields a high NPV in detecting stenosis of at least 50% on coronary CTA. As a second "reader," the CAD algorithm may help to exclude significant coronary stenosis in patients with acute chest pain at an emergency department.

Diagnostic accuracy of multidetector computed tomography coronary angiography in 330 consecutive patients referred for balloon-expandable transcatheter aortic valve implantation

Purpose: The aim of this study was to assess the evaluability and diagnostic accuracy of the multidetector computed tomography (MDCT) coronary angiography in patients referred for transcatheter aortic valve implantation (TAVI). MDCT is playing an increasingly role in patients scheduled for TAVI, providing detailed anatomic assessment of the aortic root and valve annulus and of iliofemoral access. However, the diagnostic performance of MDCT coronary angiography has not been well investigated. Methods: 330 consecutive patients scheduled for invasive coronary angiography (ICA) and 64-slice MDCT for the screening protocol before TAVI were enrolled (42 patients with previous coronary artery bypass graft (CABG), 49 with previous coronary stenting, 233 without previous revascularizations). All MDCT coronary angiography were performed using the same data set dedicated to the standard MDCT evaluation of aortic annulus, obtained with retrospective ECG triggering. Coronary arteries evaluability by MDCT coronary angiography and its diagnostic accuracy parameters in comparison with ICA as gold standard were evaluated. Results: In the remaining 325 patients, the mean HR during the scan was 61±9 bpm. The MDCT evaluability of native coronary arteries was 95.6%. The leading cause of unevaluability was the beam-hardening artifact due to large coronary calcifications (109 cases), followed by slice misalignments (56 cases) due to HR variability or premature heart beats during the scan and motion artifacts (40 cases). In the segment-based analysis, sensibility, specificity, positive predictive value, negative predictive value and accuracy were 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. MDCT correctly assessed the patency of all CABG, without graft classified as non evaluable. The MDCT evaluability of coronary stents was 82.1%. In the segment-based analysis, MDCT showed sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥ 50% luminal narrowing of 94.1%, 86.7%, 66.7%, 98.1% and 88.3%, respectively. Conclusions: MDCT coronary angiography allows to correctly rule out the presence of significant coronary stenosis in patients referred for TAVI, demonstrating and excellent negative predictive value also in patients with previous CABG or stents.

Clinical impact of coronary artery spasm in patients with no significant coronary stenosis in acute coronary syndromes

Background and objectiveTo clarify the clinical features of coronary artery spasm (CAS) with no significant coronary stenosis in patients with suspected acute coronary syndrome (ACS) in real practice. MethodsThis is a retrospective observational study of patients with suspected ACS (n=645) based on symptoms, electrocardiographic changes, and/or positive cardiac biomarkers and vasospastic angina (VSA, n=90). ACS patients were divided into two groups: (1) organic ACS (n=515), culprit lesion ≥75% coronary stenosis with/without thrombosis; (2) spastic ACS (n=70), coronary stenosis <75%, either with positive acetylcholine (ACh) test (n=51) or without ACh test but verified spontaneous spasm (n=19). The study compared clinical characteristics among organic ACS, spastic ACS, and VSA. ResultsOne hundred and thirty suspected ACS patients had a coronary organic stenosis <75% (130/645, 20%). Seventy of those patients (70/130, 54%) were confirmed to have CAS, and these accounted for 11% of all ACS patients (70/645). The rate of cigarette smoking was highest in the spastic ACS. No spastic ACS patients died during their hospital stay or after discharge, whereas acute myocardial infarction occurred in 19%, aborted sudden cardiac death in 6%, multivessel spasm was provoked in 78%, and diffuse spasm was more frequently provoked than in the VSA group (82% vs. 62%). ConclusionsCAS is not a rare cause of ACS. Although the prognosis of spastic ACS is good, there are occasional critical cases. An initial differential diagnosis including an ACh test is thus important to decide the treatment strategy of ACS.

Hybrid SPECT/CT Imaging in the Evaluation of Coronary Stenosis: Role in Diabetic Patients.

Purpose. Our purpose was to combine the results of the MDCT (multidetector computed tomography) morphological data and the SPECT (single-photon emission computed tomography) data using hybrid imaging to overcome the limits of the MDCT in the evaluation of coronary stenosis in diabetic patients with large amount of calcium in the coronary arteries. Method and Materials. 120 diabetic patients underwent MDCT examination and SPECT examination. We evaluated 324 coronary arteries. After the examinations, we merged CT and SPECT images. Results. CT evaluation: 52 (32.8%) coronaries with stenosis ≥ 50%, 228 (70.4%) with stenosis < 50%, and 44 (13.6%) with a doubtful evaluation. SPECT evaluation: 80 (24.7%) areas with hypoperfusion, 232 (71.6%) with normal perfusion, and 12 (3.7%) with a doubtful evaluation. Of 324 coronary arteries and corresponding areas, the hybrid SPECT/CT evaluation showed 92 (28.4%) areas with hypoperfusion, and 232 (71.6%) with normal perfusion. Conclusion. Hybrid CT/SPECT imaging could be useful in the detection of significant coronary stenosis in patients with large amount of coronary calcifications.