Subsequent Invasive Coronary Angiography Research Articles

Cost-effectiveness of ultrahigh-resolution photon-counting detector coronary CT angiography for the evaluation of stable chest pain

BackgroundThe increased specificity of ultrahigh-resolution (UHR) photon-counting detector (PCD)-CT over energy-integrating detector (EID)-CT for coronary CT angiography (CCTA) could defer unwarranted downstream tests. The objective of the study was to simulate the cost-effectiveness of UHR CCTA in stable chest pain patients with coronary calcifications. MethodsA decision and simulation model was developed using Monte Carlo simulations with 1000 bootstrap resamples to estimate the costs associated with PCD-CT in lieu of EID-CT for CCTA and the referral for subsequent testing. The model was constructed using the diagnostic accuracy metrics of 55 coronary lesions in patients who underwent CCTA on both CT systems and subsequent invasive coronary angiography (ICA). Sensitivity and specificity were defined for each Coronary Artery Disease Reporting and Data System category. The aggregate healthcare expenditures were derived from the hospital billing system. ResultsAssuming a projected cohort of 15,000 patients over the lifetime of the PCD-CT, its implementation resulted in a 18.9 ​% reduction in the number of functional follow-up tests (6330.3 ​± ​59.5 vs. 5135.7 ​± ​60.6, p ​< ​0.001), a 6.0 ​% reduction in performed ICAs (1447.7 ​± ​36.2 vs. 1360.2 ​± ​34.7, p ​< ​0.001), and a 9.4 ​% decrease in major procedure-related complications. Over a 10-year expected life expectancy, PCD-CT led to an average cost saving of $794.50 ​± ​18.50 per patient and an overall cost difference of $11,917,500 ​± ​4,350,169. ConclusionsPCD-CT has the potential to reduce the financial burden on healthcare systems and procedure-related complications for stable chest pain patients with coronary calcification when compared to EID-CT.

Coronary CT angiography instead of invasive angiography before TAVI: Feasibility and outcomes

AimsConcomitant coronary artery disease (CAD) is frequent in transcatheter aortic valve implantation (TAVI) candidates. Despite societal recommendations of performing invasive coronary angiography (ICA) for coronary assessment in the pre-TAVI diagnostic workup, the prognostic value of ICA and beneficial effect of revascularization in these patients remains unclear.We aimed to determine feasibility and outcomes following a strategy of cardiac CT + coronary CT angiography (cCTA) rather than cardiac CT + ICA before TAVI. Methods and resultsWe performed a single-center, observational cohort study including all patients, without previous coronary intervention, referred to TAVI between April 2020 and November 2021. CAD was assessed by cCTA, and only patients with proximal stenosis >70 %, or left main stenosis >50 %, or cCTA was non-evaluable regarding proximal segments were subsequently referred to ICA.240 patients were included in the study. No adverse effects to pre-cCTA-scan nitroglycerin administration were observed. On cCTA, 92 % of the patients had atheroscerosis. 191 (80 %) patients had cCTA only performed, while 49 (20 %) patients underwent subsequent ICA. During a median (range) follow-up of 15 (Abdel-Wahab et al., 2012; Rapp et al., 2001; Sabbah et al., 2021; Gautier et al., 2011; Sankaramangalam et al., 2017; Otto et al., 2021; Tarantini et al., 2023; Vahanian et al., 2021; Faroux et al., 2019; Ferraro et al., 2020; Patterson et al., 2021; Blanke et al., 2019; Bleakley and Monaghan, 2018; Knuuti et al., 2020; Moss et al., 2017; van den Boogert et al., 2018; Collet et al., 2018; Linde et al., 2020; Schmidt et al., 2018; Hansson et al., 2013 [6–25]) months, no difference in procedural complication rates, mortality rates, or number of unplanned ICA was observed between patients evaluated with only cCTA vs cCTA+ICA. ConclusionsUpfront cCTA instead of ICA for assessment of obstructive CAD in the diagnostic workup of patients with severe aortic stenosis referred to TAVI is feasible, safe, and with similar procedural and clinical outcomes. Randomized studies are warranted to further validate the safety of using CTA rather than ICA for coronary assessment in TAVI candidates.

Diagnostic Performance and Clinical Impact of Photon-Counting Detector Computed Tomography in Coronary Artery Disease.

Photon-counting detector-computed tomography (PCD-CT) has emerged as a promising technology, offering improved spatial resolution. This study aimed to evaluate the clinical impact and diagnostic performance of PCD-CT vs conventional energy-integrating detector computed tomography (EID-CT) for obstructive coronary artery disease (CAD). From 2022 to 2023, we retrospectively identified 7,833 consecutive patients who underwent clinically indicated coronary computed tomography angiography (CCTA) at a single center, with either PCD-CT (n=3,876; NAEOTOM Alpha [Siemens Healthineers]) or EID-CT (n=3,957; Revolution Apex 256 [GE HealthCare] or Aquilion ONE ViSION 320 [Canon Medical Systems]) scanners. Subsequent invasive coronary angiography (ICA) and percutaneous or surgical revascularization were performed as part of routine clinical care. Among those referred for ICA after coronary CTA, the presence of obstructive CAD in each vessel was determined by coronary CTA (severe stenosis on visual assessment per the Coronary Artery Disease Reporting and Data System) and ICA (≥50% diameter stenosis on quantitative coronary angiography) in a blinded fashion. The diagnostic performance of EID-CT and PCD-CT was compared by using quantitative coronary angiography as the reference standard. Patients who underwent PCD-CT were less frequently referred to subsequent ICA than those undergoing EID-CT (9.9% vs 13.1%; P< 0.001). Among those who underwent ICA, revascularization was more frequently performed in the PCD-CT group than in the EID-CT group (43.4% vs 35.5%; P=0.02). In the vessel-level analysis (n=1,686), specificity (98.0% vs 93.0%; P< 0.001), positive predictive value (83.3% vs 63.0%; P=0.002), and diagnostic accuracy (97.2% vs 92.8%; P< 0.001) were improved by PCD-CT. Sensitivity (90.9% vs 90.7%; P=0.95) and negative predictive value (98.9% vs 98.7%; P=0.83) for obstructive CAD were similar between the PCD-CT and EID-CT groups, respectively. PCD-CT exhibited excellent diagnostic performance for detecting obstructive CAD. Compared with patients undergoing conventional EID-CT, fewer patients were referred to ICA after PCD-CT, but those referred were more likely to undergo revascularization.

[15O]H2O myocardial perfusion positron emission tomography: Added value of relative stress perfusion deficit in the prediction of significant coronary artery stenosis in a mixedpopulation

BackgroundIt remains unknown whether estimation of the relative stress perfusion deficit offers added value in the prediction of significant coronary artery stenosis in myocardial perfusion imaging with [15O]H2O positron emission tomography (PET) in a population with high prevalence of established cardiac disease. MethodsDuring eight months, we consecutively included all patients undergoing [15O]H2O PET and subsequent invasive coronary angiography (ICA). Significant stenosis was defined from ICA as fractional flow reserve ≤.8 or coronary artery narrowing of ≥70%. We calculated absolute and relative total perfusion deficits (aTPD and rTPD, respectively) as semiquantitative measures of the extent and severity of reduced stress perfusion. A multivariate logistic regression analysis was performed to test the adjusted associations (odds ratio (OR) with 95% CI) with significant coronary artery stenosis. ResultsOf 800 patients undergoing [15O]H2O PET, 144 underwent ICA, where 142 patients had aTPD of ≥3% and 79 (55%) of these had at least one significant stenosis. In an adjusted analysis, rTPD (OR10% increase = 2.12 (1.44-3.12), P < .001), previous coronary artery bypass grafting (CABG) (OR = .11 (.03-.36), P < .001) and reduced left ventricular ejection fraction (LVEF) (OR = .25 (.08-.84), P = .02) were independently associated with significant stenosis, whereas the association with aTPD (OR10% increase = 1.14 (.98-1.32), P = .08) was modest. ConclusionsIn the presence of an absolute perfusion deficit (aTPD of ≥3%), rTPD may improve the prediction of significant stenosis in a heterogeneous population of patients examined with [15O]H2O PET. Furthermore, previous CABG and reduced LVEF are associated with nonstenotic perfusion deficiencies, suggesting caution when interpreting myocardial perfusion imaging in such patients.

Super-resolution deep learning reconstruction to improve image quality of coronary CT angiography

Abstract Purpose To compare the objective and subjective image quality and diagnostic performance for coronary stenosis of normal-dose model-based iterative reconstruction and reduced-dose super-resolution deep learning reconstruction in coronary CT angiography. Materials and Methods This single-center retrospective study included 52 patients (mean age, 68 years ± 10 [SD]; 41 men) who underwent serial coronary CT angiography and subsequent invasive coronary angiography between January and November 2022. The first 25 patients were scanned with a standard dose using model-based iterative reconstruction. The last 27 patients were scanned with a reduced dose using super-resolution deep learning reconstruction. Per-patient objective and subjective image qualities were compared. Diagnostic performance of model-based iterative reconstruction and super-resolution deep learning reconstruction to diagnose significant stenosis on coronary angiography was compared per-vessel using receiver operating characteristics curve analysis. Results The median tube current of super-resolution deep learning reconstruction was lower than that of model-based iterative reconstruction (median [IQR], 890 mA [680, 900] vs. 900 mA [895, 900], P = 0.03). Image noise of super-resolution deep learning reconstruction was lower than that of model-based iterative reconstruction (14.6 Hounsfield units ± 1.3 vs. 22.7 Hounsfield units ± 4.4, P &amp;lt; .001). Super-resolution deep learning reconstruction improved the overall subjective image quality compared with model-based iterative reconstruction (median [IQR], 4 [3, 4] vs 3 [3, 3], P = .006). No difference in the area under the receiver operating characteristic curve in diagnosing coronary stenosis using super-resolution deep learning reconstruction (0.96; 95% CI, 0.92-0.99) and model-based iterative reconstruction (0.96; 95% CI, 0.92-0.98; P = .98) was observed. Conclusion Our exploratory analysis suggests that super-resolution deep learning reconstruction could improve image quality with lower tube current settings than model-based iterative reconstruction with similar diagnostic performance to diagnose coronary stenosis in coronary CT angiography.

Association Between Red Blood Cell Distribution Width and Coronary Calcification in Patients Referred for Invasive Coronary Angiography.

This study aimed to determine whether red cell distribution width (RDW) is associated with coronary calcification. A total of 4796 patients who underwent coronary computed tomography angiography and subsequent invasive coronary angiography were consecutively enrolled. Coronary artery calcium score (CACS), demographic, clinical, and laboratory data were collected from electronic medical records. RDW were expressed in two forms, as a coefficient of variation (CV) or as a standard deviation (SD). Multivariable ordinal logistic regression was used to investigate the association of RDW with CACS grades (CACS 0-99, 100-399, 400-999, and >1000). A significant association was found between elevated RDW-SD and higher CACS grades after full adjustment (adjusted OR per 1-SD increase: 1.11, 95% CI: 1.05-1.18; P < .001), while no significant association was found between RDW-CV and CACS grades. When RDW-SD was analyzed as a categorical variable, it was primarily the 4th quartile of RDW-SD that was associated with elevated CACS grades compared with the 1st quartile (adjusted OR: 1.25, 95% CI: 1.07-1.46; P = .006), while the 2nd and 3rd quartiles showed no significantly higher risk. RDW-SD is a more robust biomarker for coronary calcification compared with RDW-CV.

Machine learning-based coronary artery calcium score predicted from clinical variables as a prognostic indicator in patients referred for invasive coronary angiography.

Utilising readily available clinical variables, we aimed to develop and validate a novel machine learning (ML) model to predict severe coronary calcification, and further assessed its prognostic significance. This retrospective study enrolled patients who underwent coronary CT angiography and subsequent invasive coronary angiography. Multiple ML algorithms were used to train the models for predicting severe coronary calcification (cardiac CT-measured coronary artery calcium [CT-CAC] score ≥ 400). The ML-based CAC (ML-CAC) score derived from the ML predictive probability was stratified into quartiles for prognostic analysis. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Overall, 5785 patients were divided into training (80%) and test sets (20%). For clinical practicability, we selected the nine-feature support vector machine model with good and satisfactory performance regarding both discrimination and calibration based on five repetitions of the 10-fold cross-validation in the training set (mean AUC = 0.715, Brier score = 0.202), and based on the test in the test set (AUC = 0.753, Brier score = 0.191). In the test set cohort (n = 1137), the primary endpoint was observed in 50 (4.4%) patients during a median 2.8 years' follow-up. The ML-CAC system was significantly associated with an increased risk of the primary endpoint (adjusted hazard ratio for trend 2.26, 95% CI 1.35-3.79, p = 0.002). There was no significant difference in the prognostic value between the ML-CAC and CT-CAC systems (C-index, 0.67 vs. 0.69; p = 0.618). ML-CAC score predicted from clinical variables can serve as a novel prognostic indicator in patients referred for invasive coronary angiography. In patients referred for invasive coronary angiography who have not undergone preoperative CT-measured coronary artery calcium scoring, machine learning-based coronary artery calcium score assessment can serve as an alternative for predicting the prognosis. • The coronary artery calcium (CAC) score, a solid prognostic indicator, can be predicted using non-CT methods. • We developed a machine learning (ML)-CAC model utilising nine clinical variables to predict severe coronary calcification. • The ML-CAC system offers significant prognostic value in patients referred for invasive coronary angiography.

Photon-counting detector CT reduces the rate of referrals to invasive coronary angiography as compared to CT with whole heart coverage energy-integrating detector

BackgroundWe sought to compare the degree of maximal stenosis and the rate of invasive coronary angiography (ICA) recommendations in patients who underwent coronary CT angiography (CCTA) with photon-counting detector CT (PCD-CT) versus those who underwent CCTA with whole heart coverage energy-integrating detector CT (EID-CT). MethodsIn our retrospective single-center study, we included consecutive patients with suspected CAD who underwent CCTA performed with either PCD-CT or a 280-slice EID-CT. The degree of coronary stenosis was classified as no CAD, minimal (1–24 ​%), mild (25–49 ​%), moderate (50–69 ​%), severe stenosis (70–99 ​%), or occlusion. ResultsA total of 812 consecutive patients were included in the analysis, 401 patients scanned with EID-CT and 411 patients with PCD-CT (mean age: 58.4 ​± ​12.4 years, 45.4 ​% female). Despite the higher total coronary artery calcium score (CACS) in the PCD-CT group (10 [interquartile range (IQR) ​= ​0–152.8] vs 1 [IQR ​= ​0–94], p ​< ​0.001), obstructive CAD was more frequently reported in the EID-CT vs PCD-CT group (no CAD: 28.7 ​% vs 26.0 ​%, minimal: 23.2 ​% vs 30.9 ​%, mild: 19.7 ​% vs 23.4 ​%, moderate: 14.5 ​% vs 9.7 ​%, severe: 11.5 ​% vs 8.5 ​% and occlusion: 2.5 ​% vs 1.5 ​%, respectively, p ​= ​0.025). EID-CT was independently associated with downstream ICA (OR ​= ​2.76 [95%CI ​= ​1.58–4.97] p ​< ​0.001) in the overall patient population, in patients with CACS<400 (OR ​= ​2.18 [95%CI ​= ​1.13–4.39] p ​= ​0.024) and in patients with CACS≥400 (OR ​= ​3.83 [95%CI ​= ​1.42–11.05] p ​= ​0.010). ConclusionIn patients who underwent CCTA with PCD-CT the number of subsequent ICAs was lower as compared to patients who were scanned with EID-CT. This difference was greater in patients with extensive coronary calcification.

Abstract 18188: Positron Emission Tomography Has Robust Negative Predictive Value for Development of Clinically Significant Cardiac Allograft Vasculopathy Over Time

Introduction: Cardiac allograft vasculopathy (CAV) affects &gt;50% of OHT recipients by 10 years and is a leading cause of mortality. Standard CAV screening is via invasive coronary angiography (ICA). Recently it has been shown that PET with myocardial blood flow (PET/MBF) has excellent diagnostic ability for CAV, however, its prognostic value is not known. Hypothesis: CAV assessment by PET/MBF can prognosticate lack of significant angiographic progression of CAV over meaningful time scales. Methods: A retrospective analysis of 206 OHT recipients who underwent a PET/CT between ICAs was performed. CAV progression over time was assessed using intra-patient sequences of 1) baseline ICA, 2) interval PET, and 3) subsequent ICA. PET CAV grades were determined using the algorithm in Table 1. For each interval, NPV of CAV development was calculated. Results: Intervals between ICAs of 600, 800, 1000, and 1200 days were included with 77, 114, 106, and 22 patients respectively. Sequences were analyzed if the PET fell within middle third of interval. For development of ISHLT CAV 2/3 on subsequent ICA, PET CAV 0/1 had an NPV of 0.91, 0.94, 0.91, and 0.86 at each respective time point. For development of meaningful ISHLT CAV (presence of ≥ 30% vessel stenosis) on subsequent ICA, PET CAV 0/1 had an NPV of 0.80, 0.85, 0.85, 0.8 respectively (Figure 1). Conclusions: Non-invasive CAV assessment by PET/MBF provides robust NPV for development of varying degrees of clinically significant CAV over intervals up to 4 years. PET may be used as an adjunct to ICA for CAV screening and is a viable alternative among those with reasonable risk profiles. Prospective studies are needed to determine optimal interval lengths.

Incremental value of computed tomography angiographic derived fractional flow reserve in patients with stable chest pain and anatomical obstructive coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) is endorsed by guidelines for the evaluation of obstructive coronary artery disease (OCAD) (1). However, real-world impact of selective use of FFRCT in patients with suspected OCAD by CCTA on subsequent invasive coronary angiography (ICA) and revascularization remains unclear. Purpose To assess the impact and diagnostic accuracy of FFRCT interpretation in patients with suspected OCAD by CCTA on downstream ICA and revascularization. Methods All consecutive patients who underwent coronary CCTA for the evaluation of stable chest pain between 01/10/2013 and 28/05/2021 in our tertiary university hospital were included in a registry. From a total population of 7541 patients, 1601 with reported anatomical obstructive OCAD on CCTA, were included in our study. OCAD was defined as the presence of a stenosis ≥ 50% in at least one of the three main vessels. CCTA were selectively send to FFRCT analysis according to radiologist's decision. A numerical interpretation of FFRCT was firstly performed by defining a lowest distal value≤ 0.8 as a possible need for revascularization and secondly, a comprehensive interpretation of FFRCT was completed by an experienced interventional cardiologist and radiologist. In brief, this interpretation takes into account not only the lowest distal FFRCT value, but also the post-stenotic FFR, the trans-lesional gradient and anatomical distribution of FFRCT changes. Results From a registry of 7541 patients, suspected OCAD derived from CCTA was reported in 1601 cases, including 808 (50.5%) patients evaluated by FFRCT. ICA was performed in 1160 (72.5%) and revascularization in 559 (34.9%) patients. Overall proportion of ICA decreased from 77.2 to 67.8% with FFRCT use (chi² p&amp;lt;0.01) (Figure 1). After propensity score weighting, FFRCT use was independently associated with decreased ICA (OR: 0.66; 95% CI 0.53–0.83, p&amp;lt; 0.001) and with a decreased rate of myocardial revascularization (OR: 0.71; 95% CI 0.58 –0.88, p&amp;lt; 0.01). Compared to a numerical interpretation, a comprehensive assessment of FFRCT increased the ratio of revascularization per ICA (61.8 vs 50.2 %, p&amp;lt; 0.01) and was more accurate to rule-in OCAD patient requiring a myocardial revascularization (Figure 2). After propensity score adjustment, numerically abnormal FFRCT and pathological coronary disease distribution on comprehensive assessment similar were still independently associated with an increased the rate of ICA use (OR:3.03 95% CI 2.18–4.23, p&amp;lt; 0.001 and OR: 3.45; 95% CI 2.47–4.82, p&amp;lt; 0.001, respectively) and myocardial revascularization (OR:5.13; 95% CI 3.23–8.15, p&amp;lt; 0.001 and OR:6.48; 95% CI 4.55–9.22, p&amp;lt; 0.001, respectively). Conclusion We observed in a large single-center real-world registry that implementing FFRCT downstream ICA and that a comprehensive assessment of FFRCT ensures an improved selection of patients requiring myocardial revascularization.

Validation of coronary CTA based-British cardiovascular intervention society Jeopardy score (CT-BCIS-JS) against invasive BCIS-JS - a feasibility and reproducibility study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Promedica Stiftung and the Iten-Kohaut Foundation in collaboration with the USZ Foundation Background/Introduction The invasive British Cardiovascular Intervention Society Jeopardy Score (iBCIS-JS) is a simple angiographic scoring system, enabling quantification of the extent of jeopardized myocardium related to clinically significant coronary artery disease (CAD). Ranging from 0 (no significant CAD) to 12 (CAD jeopardizing the whole LV- myocardium), the score is used for the entire spectrum of CAD including left main coronary artery and coronary artery bypass graft disease. A score of ≥6 identifies patients with anatomically high-risk CAD. Non-invasive CAD assessment with coronary CTA is hampered by modest specificity, leading potentially to increased utilization of downstream diagnostic tests. Purpose To validate coronary CTA-based assessment of the BCIS-JS (CT-BCIS-JS) against the iBCIS-JS and to assess its feasibility and reproducibility. Methods A total of 137 patients who underwent clinically indicated coronary CTA and subsequent invasive coronary angiography within 90 days were included in the analysis. Eleven patients were excluded due to suboptimal CTA image quality. CT-BCIS-JS and iBCIS-JS were calculated. Correlations were assessed with the Spearman’s rank correlation coefficient and agreement between scores with Bland-Altman (BA) analysis and with weighted kappa statistics. Inter-observer variability was investigated in a subset of 51 randomly selected patients. Results Median and interquartile range (IQR) of CT-BCIS-JS was 4 (IQR=8) and of iBCIS-JS 4 (IQR=8) (Figure 1). A CT-BCIS-JS of ≥6 and was observed in 56 (44%) patients and an iBCIS-JS of ≥6 in 54 patients (43%). An excellent correlation between the iBCIS-JS and the CT-BCIS-JS was observed (rho=0.97, p&amp;lt;0.0001; Figure 2A) with high agreement (BA bias 0.1 and limits of agreement −2.0 to 2.2; Figure 2B). Kappa analysis demonstrated excellent aagreement for identification of a iBCIS-JS of ≥6 (Kappa Weighted= 0.94, 95% CI 0.87–0.99). Inter-observer analysis revealed excellent correlation (rho=0.98, p&amp;lt;0.0001) and agreement (BA bias 0.12 and limits of agreement −1.33 to 1.57). Conclusions The CT-BCIS-JC represents a feasible and highly reproducible tool for accurate, non-invasive identification of patients with anatomically high-risk CAD. Hence, the CT-BCIS-JC may serve as reliable gatekeeper for invasive testing in the management of patients with CAD.

Epicardial adipose tissue and obstructive coronary artery disease in acute chest pain: the EPIC-ACS study.

We tested the hypothesis that epicardial adipose tissue (EAT) quantification improves the prediction of the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department. Within this prospective observational cohort study, we included 657 consecutive patients (mean age 58.06 ± 18.04 years, 53% male) presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, haemodynamic instability, or known CAD were excluded. As part of the initial workup, we performed bedside echocardiography for quantification of EAT thickness by a dedicated study physician, blinded to all patient characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as the presence of obstructive CAD, as detected in subsequent invasive coronary angiography. Patients reaching the primary endpoint had significantly more EAT than patients without obstructive CAD (7.90 ± 2.56 mm vs. 3.96 ± 1.91 mm, P < 0.0001). In a multivariable regression analysis, a 1 mm increase in EAT thickness was associated with a nearby two-fold increased odds of the presence of obstructive CAD [1.87 (1.64-2.12), P < 0.0001]. Adding EAT to a multivariable model of the GRACE score, cardiac biomarkers and traditional risk factors significantly improved the area under the receiver operating characteristic curve (0.759-0.901, P < 0.0001). Epicardial adipose tissue strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department. Our results suggest that the assessment of EAT may improve diagnostic algorithms of patients with acute chest pain.

Clinical outcomes of a CT protocol for simultaneous examination of the aorta and coronary artery in patients with aortic aneurysm.

In patients with aortic aneurysm (AA), coronary artery disease (CAD) increases the risk of perioperative complications and even asymptomatic CAD isassociated with adverse clinical outcomes. We aimed to compare coronary-aorta CT (CACT) with thoracoabdominal CT angiography (Aorta CT) for CAD management and clinical outcomes in these patients. We enrolled 479 patients undergoing CACT and 693 patients undergoing Aorta CT as an initial CT scan for AA. The primary outcome was a composite of all-cause death or myocardial infarction (MI) at 3 years after CT. The secondary outcomes were subsequent CAD management and invasive coronary angiography (CAG). After index CT scan, the CACT group had a significantly higher rate of coronary revascularization compared with the Aorta CT group (10.7% vs. 3.8%, p < 0.001) but a lower probability of diagnostic CAG among total invasive CAG (32% vs. 55%, p < 0.001). At 3 months after the CT scan, the prescription rates of statins (65.8% vs. 44.6%, p < 0.001) and antiplatelet agents (57.6% vs. 43.9%, p < 0.001) were higher in the CACT group. During follow-up, the CACT group had a significantly lower incidence of the composite outcome of all-cause death or MI (adjusted HR 1.72, 95% CI 1.07-2.78, p = 0.027) than the Aorta CT group. Among patients with AA, CACT was associated with a higher rate of subsequent CAD management and a lower risk of all-cause death or MI compared to Aorta CT. When evaluating with AA using CT, simultaneous coronary and aortic evaluation using CACT would be recommended over Aorta CT.

Likelihood reclassification by an acoustic-based score in suspected coronary artery disease

ObjectiveValidation studies of the 2019 European Society of Cardiology pretest probability model (ESC-PTP) for coronary artery disease (CAD) report that 35%–40% of patients have low pretest probability (ESC-PTP 5% to...

Second-Line Myocardial Perfusion Imaging to Detect Obstructive Stenosis: Head-to-Head Comparison of CMR and PET

BackgroundGuidelines recommend verification of myocardial ischemia by selective second-line myocardial perfusion imaging (MPI) following a coronary computed tomography angiography (CTA) with suspected obstructive coronary artery disease (CAD). Head-to-head data on the diagnostic performance of different MPI modalities in this setting are sparse. ObjectivesThe authors sought to compare, head-to-head, the diagnostic performance of selective MPI by 3.0-T cardiac magnetic resonance (CMR) and 82rubidium positron emission tomography (RbPET) in patients with suspected obstructive stenosis at coronary CTA using invasive coronary angiography (ICA) with fractional flow reserve (FFR) as reference. MethodsConsecutive patients (n = 1,732, mean age: 59.1 ± 9.5 years, 57.2% men) referred for coronary CTA with symptoms suggestive of obstructive CAD were included. Patients with suspected stenosis were referred for both CMR and RbPET and subsequently ICA. Obstructive CAD was defined as FFR ≤0.80 or >90% diameter stenosis by visual assessment. ResultsIn total, 445 patients had suspected stenosis on coronary CTA. Of these, 372 patients completed both CMR, RbPET and subsequent ICA with FFR. Hemodynamically obstructive CAD was identified in 164 of 372 (44.1%) patients. Sensitivities for CMR and RbPET were 59% (95% CI: 51%-67%) and 64% (95% CI: 56%-71%); P = 0.21, respectively, and specificities 84% (95% CI: 78%-89%) and 89% (95% CI: 84%-93%]); P = 0.08, respectively. Overall accuracy was higher for RbPET compared with CMR (73% vs 78%; P = 0.03). ConclusionsIn patients with suspected obstructive stenosis at coronary CTA, CMR, and RbPET show similar and moderate sensitivities but high specificities compared with ICA with FFR. This patient group represents a diagnostic challenge with frequent mismatch between advanced MPI tests and invasive measurements. (Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 2 [Dan-NICAD 2]; NCT03481712)

The Utility of Coronary CT Angiography in Evaluating Symptomatic Patients with Positive MPI Referred for Coronary Angiography: A Single-center Experience

Background: Patients with suspected or known coronary artery disease (CAD) can be challenging to evaluate. Our study aims to assess the efficacy and utility of coronary computed tomographic angiography (CCTA) as a diagnostic method in patients with abnormal myocardial perfusion imaging (MPI) who were initially referred for Invasive Coronary Angiography (ICA). Methods: This is a single-center retrospective descriptive study. We evaluated 210 patients who underwent CCTA instead of ICA. Data of these patients were documented and analyzed accordingly. Results: Of the 210 patients who underwent CCTA, the procedure was found to be diagnostic in 172 (81.9%) patients. Of these 172 patients, 152 (88.4%) had normal coronaries or minor CAD, and 20 (11.6%) had significant disease requiring subsequent ICA. In 38 (18.1%) patients out of the total cohort, the CCTA was not diagnostic or could not be performed due to technical difficulties, requiring either ICA or another ischemia evaluation diagnostic modality. Conclusion: CCTA is a viable and reliable diagnostic tool for evaluating patients with suspected CAD referred for ICA following an abnormal MPI test. It is recommended as an initial test to rule out significant coronary stenosis and as it can avoid unnecessary ICA.

Utility of gated SPECT parameters in detection of coronary artery disease in patients with normal perfusion images

BackgroundFalse negative myocardial perfusion images on single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is a substantial problem in the interpretation of MPI. To explore possible parameters from gated SPECT that could detected coronary artery disease (CAD) in patients with normal perfusion images, we retrospectively selected patients who underwent a 2-day Tc-99 m MIBI adenosine stress/rest MPI and a subsequent invasive coronary angiography. Gated SPECT parameters, including end systolic volume (ESV), end diastolic volume (EDV), left ventricular ejection fraction (LVEF), and transient ischemic dilation (TID) ratio of patients with and without CAD were compared and assessed for their respective diagnostic performance using receiver operating characteristics (ROC) area under the curve (AUC).ResultsAmong 22 patients with normal perfusion images, 7 patients had CAD. Despite the small number of patients, we found significant differences between the ESV, the EDV, and the LVEF between patients with and without CAD. The analysis of ROC curve showed the stress ESV could excellently detect CAD (AUC = 0.900). The rest ESV, the stress EDV, the rest EDV, the stress LVEF and the rest LVEF could likewise perform well in the detection of CAD (AUC = 0.833, 0.819, 0.790, 0.862, and 0.838, respectively). In contrast, the change in LVEF and the TID ratio (AUC = 0.667 and 0.524, respectively) did not seem as reliable as other parameters. Optimal cutoffs for detection of CAD in patients with normal perfusion images from our study were ≥ 20.0 mL for the stress ESV, ≥ 71.0 mL for the stress EDV, ≤ 66.3 EF units for the stress LVEF, ≥ 18.0 mL for the rest ESV, ≥ 67.0 mL for the rest EDV and ≤ 70.0 EF unit for the rest LVEF.ConclusionsGated SPECT parameters could facilitate detection of CAD in patient with normal perfusion images on Tc-99m MIBI MPI. These parameters should be carefully interpreted to improve diagnostic accuracy and reduce false negative MPI.

Centralized Triage of Suspected Coronary Artery Disease Using Coronary Computed Tomographic Angiography to Optimize the Diagnostic Yield of Invasive Angiography

BackgroundCoronary computed tomographic angiography (CCTA) is preferable to invasive coronary angiography (ICA) for coronary artery disease (CAD) diagnosis in elective patients without known CAD. MethodsWe conducted a nonrandomized interventional study involving 2 tertiary care centres in Ontario. From July 2018 to February 2020, outpatients referred for elective ICA were identified through a centralized triage process and were recommended to undergo CCTA first instead of ICA. Patients with borderline or obstructive CAD on CCTA were recommended to undergo subsequent ICA. Intervention acceptability, fidelity, and effectiveness were assessed. ResultsA total of 226 patients were screened, with 186 confirmed to be eligible, of whom 166 had patient and physician approval to proceed with CCTA (89% acceptability). Among consenting patients, 156 (94%) underwent CCTA first; 43 (28%) had borderline/obstructive CAD on CCTA, and only 1 with normal/nonobstructive CAD on CCTA was referred for subsequent ICA against protocol (99% fidelity). Overall, 119 of 156 CCTA-first patients did not have ICA within the following 90 days (i.e., 76% potentially avoided ICA, due to the intervention). Among the 36 who underwent ICA post-CCTA per protocol, 24 had obstructive CAD (66.7% diagnostic yield). If all patients who were referred for and underwent ICA at either centre between July 2016 and February 2020 (n = 694 pre-implementation; n = 333 post-implementation) had had CCTA first, an additional 42 patients per 100 would have had an obstructive CAD finding on their ICA (95% confidence interval = 26-59). ConclusionA centralized triage process, in which elective outpatients referred for ICA are instead referred for CCTA first, appears to be acceptable and effective in diagnosing obstructive CAD and improving efficiencies in our healthcare system.

Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes

BackgroundThe ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid...

Plaque composition on ultra-high-resolution coronary computed tomography angiography with optical coherence tomography correlation.

A 68-year-old man presented to our chest pain unit with angina and a low pre-test probability for coronary artery disease (CAD). Troponin levels were normal, and echocardiography showed an intact left ventricular function. Coronary computed tomography angiography (CCTA) was performed using a first-generation dual-source photon-counting detector computed tomography (PCD-CT, NAEOTOM Alpha®, Siemens Healthineers) in a novel ultra-high resolution (UHR) mode. Data were reconstructed at 0.6 and 0.2 mm to reflect the typical appearance on standard and PCD-CT scanners (Panels A/D and B/E, respectively). The RCX presented with a mixed plaque and moderate-to-severe stenosis, right coronary artery (RCA) with a soft plaque and moderate-to-severe stenosis (Panels A and B), and LAD with a mostly a calcified plaque and mild stenosis (Figure 1D). UHR reconstructions revealed a fibrous cap on the calcified plaque (Panel E). Subsequent invasive coronary angiography including optical coherence tomography (OCT) confirmed a significant stenosis in the RCA [Panel C, fibrous plaque with micro-calcifications (arrowhead)] and left circumflex coronary artery (LCX) (mostly fibrotic components). Both were successfully treated with drug-eluting stents [thrombolysis in myocardial infarction (TIMI) coronary grade flow 3 (TIMI 3)]. Further, OCT confirmed the mild stenosis of the LAD caused by lesion with a fibrous cap over the calcification (Panel F).