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De Vita A, Covino M, Pontecorvo S, Buonamassa G, Marino AG, Marano R, Natale L, Liuzzo G, Burzotta F, Franceschi F. Coronary CT Angiography in the Emergency Department: State of the Art and Future Perspectives. J Cardiovasc Dev Dis 2025; 12:48. [PMID: 39997482 PMCID: PMC11856466 DOI: 10.3390/jcdd12020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2024] [Revised: 01/16/2025] [Accepted: 01/22/2025] [Indexed: 02/26/2025] Open
Abstract
About 5% of annual access to emergency departments (EDs) and up to 25-30% of hospital admissions involve patients with symptoms suggestive of acute coronary syndrome (ACS). The process of evaluating and treating these patients is highly challenging for clinicians because failing to correctly identify an ACS can result in fatal or life-threatening consequences. However, about 50-60% of these patients who are admitted to the hospital because of chest pain are found to have no ACS. Coronary computed tomographic angiography (CCTA) has emerged as a proposed new frontline test for managing acute chest pain in the ED, particularly for patients with low-to-intermediate risk. This narrative review explores the potential of adopting an early CCTA-based approach in the ED, its significance in the era of high-sensitivity troponins, its application to high-risk patients and its prognostic value concerning atherosclerotic burden and high-risk plaque features. Additionally, we address clinical and technical issues related to CCTA use for triaging acute chest pain in the ED, as well as the role of functional testing. Finally, we aim to provide insight into future perspectives for the clinical application of CCTA in the ED.
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Affiliation(s)
- Antonio De Vita
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Marcello Covino
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Sara Pontecorvo
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
| | - Giacomo Buonamassa
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
| | - Angelo Giuseppe Marino
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
| | - Riccardo Marano
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Luigi Natale
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Giovanna Liuzzo
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Burzotta
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Franceschi
- Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (M.C.); (S.P.); (G.B.); (A.G.M.); (R.M.); (L.N.); (G.L.); (F.B.); (F.F.)
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
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Miller CD, Mahler SA, Snavely AC, Raman SV, Caterino JM, Clark CL, Jones AE, Hall ME, Koehler LE, Lovato JF, Hiestand BC, Stopyra JP, Park CJ, Vasu S, Kutcher MA, Hundley WG. Cardiac Magnetic Resonance Imaging Versus Invasive-Based Strategies in Patients With Chest Pain and Detectable to Mildly Elevated Serum Troponin: A Randomized Clinical Trial. Circ Cardiovasc Imaging 2023; 16:e015063. [PMID: 37339173 PMCID: PMC10287041 DOI: 10.1161/circimaging.122.015063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/25/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The optimal diagnostic strategy for patients with chest pain and detectable to mildly elevated serum troponin is not known. The objective was to compare clinical outcomes among an early decision for a noninvasive versus an invasive-based care pathway. METHODS The CMR-IMPACT trial (Cardiac Magnetic Resonance Imaging Strategy for the Management of Patients with Acute Chest Pain and Detectable to Elevated Troponin) was conducted at 4 United States tertiary care hospitals from September 2013 to July 2018. A convenience sample of 312 participants with acute chest pain symptoms and a contemporary troponin between detectable and 1.0 ng/mL were randomized early in their care to 1 of 2 care pathways: invasive-based (n=156) or cardiac magnetic resonance (CMR)-based (n=156) with modification allowed as the patient condition evolved. The primary outcome was a composite including death, myocardial infarction, and cardiac-related hospital readmission or emergency visits. RESULTS Participants (N=312, mean age, 60.6 years, SD 11.3; 125 women [59.9%]), were followed over a median of 2.6 years (95% CI, 2.4-2.9). Early assigned testing was initiated in 102 out of 156 (65.3%) CMR-based and 110 out of 156 (70.5%) invasive-based participants. The primary outcome (CMR-based versus invasive-based) occurred in 59% versus 52% (hazard ratio, 1.17 [95% CI, 0.86-1.57]), acute coronary syndrome after discharge 23% versus 22% (hazard ratio, 1.07 [95% CI, 0.67-1.71]), and invasive angiography at any time 52% versus 74% (hazard ratio, 0.66 [95% CI, 0.49-0.87]). Among patients completing CMR imaging, 55 out of 95 (58%) were safely identified for discharge based on a negative CMR and did not have angiography or revascularization within 90 days. Therapeutic yield of angiography was higher in the CMR-based arm (52 interventions in 81 angiographies [64.2%] versus 46 interventions in 115 angiographies [40.0%] in the invasive-based arm [P=0.001]). CONCLUSIONS Initial management with CMR or invasive-based care pathways resulted in no detectable difference in clinical and safety event rates. The CMR-based pathway facilitated safe discharge, enriched the therapeutic yield of angiography, and reduced invasive angiography utilization over long-term follow-up. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01931852.
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Affiliation(s)
- Chadwick D Miller
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Simon A Mahler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Implementation Science (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna C Snavely
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Subha V Raman
- Division of Cardiovascular Medicine (S.V.R.), The Ohio State University, Columbus, OH
- Now with Indiana University Krannert Institute of Cardiology, Indianapolis, IN (S.V.R.)
| | - Jeffrey M Caterino
- Department of Emergency Medicine (J.M.C.), The Ohio State University, Columbus, OH
| | - Carol L Clark
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (C.L.C.)
| | - Alan E Jones
- Department of Emergency Medicine (A.E.J.), University of Mississippi Medical Center, Jackson, MS
| | - Michael E Hall
- Department of Medicine (M.E.H.), University of Mississippi Medical Center, Jackson, MS
| | - Lauren E Koehler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - James F Lovato
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason P Stopyra
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn J Park
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sujethra Vasu
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael A Kutcher
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - W Gregory Hundley
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Radiology (W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Internal Medicine/Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (W.G.H.)
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Prevalence of low-attenuation plaques and statin therapy in plaque rupture type of acute coronary syndrome. Coron Artery Dis 2023; 34:11-17. [PMID: 36484215 DOI: 10.1097/mca.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We sought to investigate the differences in coronary plaque morphology on coronary computed tomography angiography (CCTA) and medical therapy between acute coronary syndrome (ACS) and stable ischemic heart disease (SIHD). We also explored the relationship between plaque morphology on CCTA at the initial phase and lesion morphology in the acute phase of ACS. METHODS In 5967 patients who underwent invasive coronary angiography, 58 ACS and 91 SIHD patients who had prior CCTA imaging of the culprit lesion and denied ischemic heart disease at CCTA scanning were enrolled. RESULTS Although the prevalence of positive remodeling was not different (P = 0.27), low-attenuation plaques (LAP) on prior CCTA were significantly higher in ACS than in SIHD (52% vs. 24%, P < 0.01). The frequency of coronary stenosis grading did not differ between the two groups (P = 0.14). In ACS patients, the frequencies of plaque rupture and lipid-rich plaque assessed by optical coherence tomography (OCT) were significantly higher in LAP than in non-LAP (73% vs. 23%, P < 0.01; 82% and 23%, P < 0.01). Multivariate regression analysis revealed that statin use and LAP on prior CCTA were predictors of future ACS events (P < 0.01, and P < 0.05, respectively). CONCLUSIONS LAP on CCTA, not positive arterial remodeling, and lack of statin therapy were associated with ACS development. In addition, LAP more frequently led to the development of the plaque rupture type of ACS compared with non-LAP. Lipid-lowering therapy with statins might be useful to prevent plaque rupture in patients with LAP regardless of coronary stenosis.
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Dahal S, Budoff MJ, Roy SK. Coronary Computed Tomography Angiography for Evaluation of Chest Pain in the Emergency Department. Tex Heart Inst J 2022; 49:e217550. [PMID: 36511943 PMCID: PMC9809099 DOI: 10.14503/thij-21-7550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronary computed tomography angiography has emerged as an important diagnostic modality for evaluation of acute chest pain in the emergency department for patients at low to intermediate risk for acute coronary syndromes. Several clinical trials have shown excellent negative predictive value of coronary computed tomography angiography to detect obstructive coronary artery disease. Cardiac biomarkers such as troponins and creatine kinase MB, along with history, electrocardiogram, age, risk factors, troponin score, and Thrombolysis in Myocardial Infarction score should be used in conjunction with coronary computed tomography angiography for safe and rapid discharge of patients from the emergency department. Coronary computed tomography angiography along with high-sensitivity troponin assays could be effective for rapid evaluation of acute chest pain in the emergency department, but high-sensitivity troponins are not always available. Emergency department physicians are not quite comfortable making clinical decisions, especially if the coronary stenosis is in the range of 50% to 70%. In these cases, further evaluation with functional testing, such as nuclear stress testing or stress echocardiogram, is a common approach in many centers; however, newer methods such as fractional flow reserve computed tomography could be safely incorporated in coronary computed tomography angiography to help with clinical decision-making in these scenarios.
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Affiliation(s)
- Suraj Dahal
- Department of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Matthew J. Budoff
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
| | - Sion K. Roy
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
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5
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Gohbara M, Iwahashi N, Okada K, Ogino Y, Hanajima Y, Kirigaya J, Minamimoto Y, Matsuzawa Y, Nitta M, Konishi M, Hibi K, Kosuge M, Ebina T, Sugano T, Ishikawa T, Tamura K, Kimura K. A Simple Risk Score to Differentiate Between Coronary Artery Obstruction and Coronary Artery Spasm of Patients With Acute Coronary Syndrome Without Persistent ST-Segment Elevation. Circ J 2022; 86:1509-1518. [PMID: 35599005 DOI: 10.1253/circj.cj-22-0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND The aim of this study was to create a risk scoring model to differentiate obstructive coronary artery (CA) from CA spasm in the etioology of acute coronary syndrome (ACS). METHODS AND RESULTS We included 753 consecutive patients with ACS without persistent ST-segment elevation (p-STE). The exclusion criteria were: (1) out-of-hospital cardiac arrest; (2) cardiogenic shock; (3) hemodialysis; (4) atrial fibrillation/flutter; (5) severe valvular disease; (6) no coronary angiography; (7) non-obstructive coronary artery without "definite" vasospastic angina definition; and/or (8) missing data. From the multivariate logistic regression analysis for prediction of obstructive CA, an integer score of 2 to each 0.5 increment in odds ratio was given, and values were divided into quartiles according to the total score. The scores were as follows: age >70 years (6 points), non-STE myocardial infarction (9 points), diabetes mellitus (5 points), B-type natriuretic peptide >90 pg/mL (7 points), neutrophil to lymphocyte ratio >2 (5 points), and high-density lipoprotein cholesterol <50 mg/dL (5 points). CA spasm-induced ACS occurred in 50.0% in Quartile 1 (total score: 0-13), 20.5% in Quartile 2 (total score: 14-19), 4.9% in Quartile 3 (total score: 20-26), and 2.2% in Quartile 4 (total score: 27-37) (P<0.001), indicating that a total score of <20 was a potential clinical indicator of CA spasm-induced ACS. CONCLUSIONS CA spasm-induced ACS should be suspected if a total score of <20, and a spasm provocation test was being considered.
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Affiliation(s)
- Masaomi Gohbara
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
- Division of Cardiology, Yokohama City University Medical Center
| | | | - Kozo Okada
- Division of Cardiology, Yokohama City University Medical Center
| | - Yutaka Ogino
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
- Division of Cardiology, Yokohama City University Medical Center
| | - Yohei Hanajima
- Division of Cardiology, Yokohama City University Medical Center
| | - Jin Kirigaya
- Division of Cardiology, Yokohama City University Medical Center
| | - Yugo Minamimoto
- Division of Cardiology, Yokohama City University Medical Center
| | | | - Manabu Nitta
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
| | - Masaaki Konishi
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
- Division of Cardiology, Yokohama City University Medical Center
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Toshiaki Ebina
- Division of Cardiology, Yokohama City University Medical Center
- Department of Laboratory Medicine and Clinical Investigation, Yokohama City University Medical Center
| | - Teruyasu Sugano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
| | - Kazuo Kimura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine
- Division of Cardiology, Yokohama City University Medical Center
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Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
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Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
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Batlle JC, Kirsch J, Bolen MA, Bandettini WP, Brown RKJ, Francois CJ, Galizia MS, Hanneman K, Inacio JR, Johnson TV, Khosa F, Krishnamurthy R, Rajiah P, Singh SP, Tomaszewski CA, Villines TC, Wann S, Young PM, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome. J Am Coll Radiol 2020; 17:S55-S69. [PMID: 32370978 DOI: 10.1016/j.jacr.2020.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/17/2022]
Abstract
Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Juan C Batlle
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida.
| | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | | | - W Patricia Bandettini
- National Institutes of Health, Bethesda, Maryland; Society for Cardiovascular Magnetic Resonance
| | | | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joao R Inacio
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology Expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear Cardiology Expert
| | | | | | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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El Merhi F, Bou-Fakhredin R, El Ashkar B, Ghieh D, Ghosn Y, Saade C. State of the art of coronary computed tomography angiography. Radiography (Lond) 2020; 26:174-182. [PMID: 32052781 DOI: 10.1016/j.radi.2019.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/21/2019] [Accepted: 10/02/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The aim of this paper is to evaluate contrast media (CM) bolus geometry and opacification patterns in the coronary arteries with particular focus on patient, scanner and safety considerations during coronary computed tomography angiography (CCTA). KEY FINDINGS The rapid evolution of computed tomography (CT) technology has seen this imaging modality challenge conventional coronary angiography in the evaluation of coronary artery disease. Increases in spatial and temporal resolutions have enabled CCTA to become the modality of choice when evaluating the coronary vascular tree as an alternative in the diagnostic algorithm for acute chest pain. However, these new technologic improvements in scanner technology have imposed new challenges for the optimisation of CM delivery and image acquisition strategies. CONCLUSION Understanding basic CM-imaging principles is essential for designing optimal injection protocols according to each specific clinical scenario, independently of scanner technology. IMPLICATIONS FOR PRACTICE With rapid advances in CT scanner technology including faster scan acquisitions, the risk of poor opacification of coronary vasculature increases significantly. Therefore, awareness of CM delivery protocols is paramount to consistently provide optimal image quality at a low radiation dose.
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Affiliation(s)
- F El Merhi
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O. Box: 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - R Bou-Fakhredin
- American University of Beirut, P.O. Box: 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - B El Ashkar
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O. Box: 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - D Ghieh
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O. Box: 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Y Ghosn
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O. Box: 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - C Saade
- Diagnostic Radiology Department, American University of Beirut Medical Center, P.O. Box: 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon.
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Mahfouz RA, Arab M, Abdelhamid M, Elzayat A. Fragmented QRS complex is an independent predictor of plaque burden in patients at intermediate risk of coronary artery disease. Indian Heart J 2020; 71:394-399. [PMID: 32035522 PMCID: PMC7013196 DOI: 10.1016/j.ihj.2019.11.254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/01/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the relationship between fragmented QRS complex and plaque burden in patients presented with typical chest pain and deemed to have intermediate pretest probability of CAD using coronary computed tomography angiography (CCTA). METHODS We studied electrocardiograms (ECGs) obtained from 172 subjects (47.5 ± 9.5 years, 125 were men) presented with chest pain and had intermediate pretest probability for CAD. The presence was found and evaluation of CAD was performed with CCTA. RESULTS Seventy four (43%) of the study cohort had CCTA-documented CAD. Meanwhile the frequency of fQRS in our cohort was (57%). 70 (71.4%) patients with fQRS had CAD compared with only 4 (5.4%) patients without fQRS (p < 0.001). The number of leads with fQRs was correlated with the calcium score (p < 0.005), segment stenosis score, segment involvement score, total plaque score (TPS), and E/e ratio (p < 0.001, for all). Multivariate analysis demonstrated that fQRS was a strong independent predictor for CAD (or = 2.15, p < 0.001). ROC analysis showed that the number of leads ≥3 was the optimal number for predicting CAD (AUC = 0.89, sensitivity 88%, and specificity 83%, p < 0.001). CONCLUSION Fragmented QRS was seen more often in patients with high plaque burden. We suggest that fQRS might provide a useful noninvasive prognosticator for subjects with intermediate pretest probability of CAD for further investigation.
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Affiliation(s)
- Ragab A Mahfouz
- Cardiology Department, Zagazig University Hospital, Algammah Street, Egypt.
| | - Mohamad Arab
- Cardiology Department, Zagazig University Hospital, Algammah Street, Egypt
| | - Mohamed Abdelhamid
- Cardiology Department, Zagazig University Hospital, Algammah Street, Egypt
| | - Ahmad Elzayat
- Cardiology Department, Zagazig University Hospital, Algammah Street, Egypt
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Kashiwagi M, Kitabata H, Tanaka A, Arita Y, Taruya A, Shimamoto Y, Yamamoto Y, Mori K, Nishiguchi T, Terada K, Ota S, Tanimoto T, Kubo T, Akasaka T. Combination of Lesion Stenosis and Myocardial Supply Area Assessed by Coronary Computed Tomography Angiography for Prediction of Myocardial Ischemia. Int Heart J 2019; 60:1238-1244. [PMID: 31735779 DOI: 10.1536/ihj.19-141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recent clinical studies revealed that anatomical information assessed by coronary computed tomography angiography (CTA) may be used effectively to diagnose coronary artery disease (CAD). However, a physiological assessment, demonstrating myocardial ischemia, is required to justify a therapeutic strategy for CAD. This study aimed to investigate whether using CTA to assess myocardial supply area can improve the prediction of myocardial ischemia.We analyzed 201 vessels with moderate (luminal narrowing ≥ 50%, < 70%) and severe (luminal narrowing ≥ 70%, < 99%) stenosis on CTA from 174 patients, who were suspected of having stable angina and underwent measurement of fractional flow reserve (FFR). The myocardial area supplied by the coronary artery, distal to the stenosis, was evaluated with CTA, as reported previously (modified Alberta Provincial Project for Outcome Assessment in Coronary Heart score) and was classified into 3 groups (large, medium, and small).Both percentage area stenosis and myocardial supply area were significantly correlated with FFR (r = -0.46, P < 0.01, and r = -0.45, P < 0.01). Among patients who had coronary plaques, with moderate stenosis and a small myocardial supply area, only 3 of 42 lesions (7%) were identified as ischemic; deviation from the ischemic threshold (FFR = 0.80) was P < 0.01. The combined assessment of lesion stenosis and myocardial supply area, using CTA, improved the prediction of myocardial ischemia significantly compared to lesion stenosis alone (77% versus 59%, P < 0.01).Adding the assessment of myocardial supply area to standard CTA might help predict myocardial ischemia in patients with stable angina pectoris.
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Affiliation(s)
| | | | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yu Arita
- Department of Cardiology, Shingu Municipal Medical Center
| | - Akira Taruya
- Department of Cardiology, Shingu Municipal Medical Center
| | | | | | - Kazuya Mori
- Department of Cardiology, Shingu Municipal Medical Center
| | | | - Kosei Terada
- Department of Cardiology, Shingu Municipal Medical Center
| | - Shingo Ota
- Department of Cardiology, Shingu Municipal Medical Center
| | | | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
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11
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Abstract
PURPOSE OF REVIEW To compare outcomes between registries and randomized controlled trials of coronary computed tomographic angiography (CCTA)-based versus standard of care approaches to the initial evaluation of patients with acute chest pain. RECENT FINDINGS Randomized trials have demonstrated CCTA to be a safe and efficient tool for triage of low- to intermediate-risk patients presenting to the emergency department with chest pain. Recent studies demonstrate heterogeneous result using different standard of care approaches for evaluation of hard endpoints in comparison with standard evaluation. Also, there has been continued concern for increase in subsequent testing after coronary CTA. Although CCTA improves detection of coronary artery disease, it is uncertain if it will bring improvement of long-term health outcomes at this point of time. Careful analysis of the previous results and further investigation will be required to validate evaluation of hard endpoints.
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12
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Bamberg F, Mayrhofer T, Ferencik M, Bittner DO, Hallett TR, Janjua S, Schlett CL, Nagurney JT, Udelson JE, Truong QA, Woodard PK, Hollander JE, Litt H, Hoffmann U. Age- and sex-based resource utilisation and costs in patients with acute chest pain undergoing cardiac CT angiography: pooled evidence from ROMICAT II and ACRIN-PA trials. Eur Radiol 2017; 28:851-860. [PMID: 28875364 DOI: 10.1007/s00330-017-4981-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine resource utilisation according to age and gender-specific subgroups in two large randomized diagnostic trials. METHODS We pooled patient-specific data from ACRIN-PA 4005 and ROMICAT II that enrolled subjects with acute chest pain at 14 US sites. Subjects were randomized between a standard work-up and a pathway utilizing cardiac computed tomography angiography (CCTA) and followed for the occurrence of acute coronary syndrome (ACS) and resource utilisation during index hospitalisation and 1-month follow-up. Study endpoints included diagnostic accuracy of CCTA for the detection of ACS as well as resource utilisation. RESULTS Among 1240 patients who underwent CCTA, negative predictive value of CCTA to rule out ACS remained very high (≥99.4%). The proportion of patients undergoing additional diagnostic testing and cost increased with age for both sexes (p < 0.001), and was higher in men as compared to women older than 60 years (43.1% vs. 23.4% and $4559 ± 3382 vs. $3179 ± 2562, p < 0.01; respectively). Cost to rule out ACS was higher in men (p < 0.001) and significantly higher for patients older than 60 years ($2860-5935 in men, p < 0.001). CONCLUSIONS CCTA strategy in patients with acute chest pain results in varying resource utilisation according to age and gender-specific subgroups, mandating improved selection for advanced imaging. KEY POINTS • In this analysis, CAD and ACS increased with age and male gender. • CCTA in patients with acute chest pain results in varying resource utilisation. • Significant increase of diagnostic testing and cost with age for both sexes. • Cost to rule out ACS is higher in men and patients >60 years. • Improved selection of subjects for cardiac CTA result in more resource-driven implementation.
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Affiliation(s)
- Fabian Bamberg
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany.
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- School of Business Studies, Stralsund University of Applied Science, Stralsund, Germany
| | - Maros Ferencik
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Daniel O Bittner
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine 2 - Cardiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Travis R Hallett
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sumbal Janjua
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher L Schlett
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James E Udelson
- Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA, USA
| | | | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Harold Litt
- Department of Radiology and Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
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13
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Durand E, Bauer F, Mansencal N, Azarine A, Diebold B, Hagege A, Perdrix L, Gilard M, Jobic Y, Eltchaninoff H, Bensalah M, Dubourg B, Caudron J, Niarra R, Chatellier G, Dacher JN, Mousseaux E. Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study. Int J Cardiol 2017; 241:463-469. [DOI: 10.1016/j.ijcard.2017.02.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/10/2016] [Accepted: 02/24/2017] [Indexed: 11/15/2022]
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14
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Stănescu A, Himcinschi E, Morariu M, Rat N, Bordi L, Rațiu M, Benedek A, Benedek I, Benedek T. Cardiac Computed Tomography Assessment in Acute Coronary Syndromes — Do We Have Time for It in Emergency Settings? JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The diagnosis and treatment of acute coronary syndrome remain a challenge for clinicians in many clinical settings, especially in patients with previous low-to-intermediate risk. Due to its high specificity and sensitivity for detecting significant coronary artery stenoses, cardiac computed tomography angiography (CCTA) tends to be used more frequently in the emergency room (ER) in the last years. This technique has been associated with a higher rate of safe discharge in patients with chest pain, less time spent in the ER, and decreased costs related to further investigations. In cases positive for coronary artery stenosis, CCTA can accurately evaluate the indication for percutaneous coronary angioplasty and can offer relevant information related to the characteristics of the coronary plaques, being able to detect vulnerable coronary plaques. The aim of this manuscript is to highlight the possibility of using CCTA in the ER in the assessment of patients with chest pain and to show the benefits of the procedure regarding safety, costs, accuracy, and time.
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Affiliation(s)
- Alexandra Stănescu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Elisabeta Himcinschi
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Mirabela Morariu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Nora Rat
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Lehel Bordi
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Mihaela Rațiu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | | | - Imre Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Theodora Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
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15
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Ruckel SM, Gulati M. Coronary Calcium Scoring as the Gate Keeper for Stress Myocardial Perfusion Imaging: Antagonist. J Nucl Cardiol 2017; 24:832-834. [PMID: 28144907 DOI: 10.1007/s12350-017-0793-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 10/24/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Shane M Ruckel
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Martha Gulati
- Division of Cardiology, University of Arizona-Phoenix, 1111 East McDowell Road, Suite 200, Phoenix, AZ, 85008, USA.
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16
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Ozaki Y, Imanishi T, Hosokawa S, Nishiguchi T, Taruya A, Tanimoto T, Kuroi A, Yamano T, Matsuo Y, Ino Y, Kitabata H, Kubo T, Tanaka A, Akasaka T. Association of Toll-Like Receptor 4 on Human Monocyte Subsets and Vulnerability Characteristics of Coronary Plaque as Assessed by 64-Slice Multidetector Computed Tomography. Circ J 2017; 81:837-845. [PMID: 28344199 DOI: 10.1253/circj.cj-16-0688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although Toll-like receptor 4 (TLR-4) is involved in monocyte activation in patients with accelerated forms of atherosclerosis, the relationship between the expression of TLR-4 on circulating monocytes and coronary plaque vulnerability has not previously been evaluated. We investigated this relationship using 64-slice multidetector computed tomography (MDCT) in patients with stable angina pectoris (SAP). METHODS AND RESULTS We enrolled 65 patients with SAP who underwent MDCT. Three monocyte subsets (CD14++CD16-, CD14++CD16+, and CD14+CD16+) and expression of TLR-4 were measured by flow cytometry. Intracoronary plaques were assessed by 64-slice MDCT. We defined vulnerability of intracoronary plaques according to the presence of positive remodeling (remodeling index >1.05) and/or low CT attenuation (<35 HU). The circulating CD14++CD16+monocytes more frequently expressed TLR-4 than CD14++CD16-and CD14+CD16+monocytes (P<0.001). The relative proportion of the expression of TLR-4 on CD14++CD16+monocytes was significantly greater in patients with vulnerable plaque compared with those without (10.4 [4.1-14.5] % vs. 4.5 [2.8-7.8] %, P=0.012). In addition, the relative proportion of TLR-4 expression on CD14++CD16+monocytes positively correlated with the remodeling index (r=0.28, P=0.025) and negatively correlated with CT attenuation value (r=-0.31, P=0.013). CONCLUSIONS Upregulation of TLR-4 on CD14++CD16+monocytes might be associated with coronary plaque vulnerability in patients with SAP.
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Affiliation(s)
- Yuichi Ozaki
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Toshio Imanishi
- Department of Cardiovascular Medicine, Wakayama Medical University
- Department of Cardiovascular Medicine, Hidaka General Hospital
| | - Seiki Hosokawa
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Akio Kuroi
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Yamano
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yoshiki Matsuo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yasushi Ino
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
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17
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Saremi F. Cardiac MR Imaging in Acute Coronary Syndrome: Application and Image Interpretation. Radiology 2017; 282:17-32. [PMID: 28005512 DOI: 10.1148/radiol.2016152849] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute coronary syndrome (ACS) is a frequent cause of hospitalization and coronary interventions. Cardiac magnetic resonance (MR) imaging is an increasingly used technique for initial work-up of chest pain and early post-reperfusion and follow-up evaluation of ACS to identify patients at high risk of further cardiac events. Cardiac MR imaging can evaluate with accuracy a variety of prognostic indicators of myocardial damage, including regional myocardial dysfunction, infarct distribution, infarct size, myocardium at risk, microvascular obstruction, and intramyocardial hemorrhage in both acute setting and later follow-up examinations. In addition, MR imaging is useful to rule out other causes of acute chest pain in patients admitted to the emergency department. In this article, a brief explanation of the pathophysiology, classification, and treatment options for patients with ACS will be introduced. Indications of cardiac MR imaging in ACS patients will be reviewed and specific cardiac MR protocol, image interpretation, and potential diagnostic pitfalls will be discussed. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Farhood Saremi
- From the Department of Radiology, University of Southern California, USC University Hospital, 1500 San Pablo St, Los Angeles CA 90033
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18
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Engel LC, Thai WE, Medina-Zuluaga H, Karolyi M, Sidhu MS, Maurovich-Horvat P, Margey R, Pomerantsev E, Abbara S, Ghoshhajra BB, Hoffmann U, Liew GY. Non-diagnostic coronary artery calcification and stenosis: a correlation of coronary computed tomography angiography and invasive coronary angiography. Acta Radiol 2017; 58:528-536. [PMID: 27614067 DOI: 10.1177/0284185116663041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Heavy coronary artery calcification (CAC) impairs diagnostic accuracy of coronary computed tomography angiography (cCTA) and is considered to be a major limitation. Purpose To investigate the effect of non-evaluable CAC seen on cCTA on clinical decision-making by determining the degree of subsequent invasive testing and to assess the relationship between non-evaluable segments containing CAC and significant stenosis as seen in invasive coronary angiography (ICA). Material and Methods The study comprised of 356 patients who underwent cCTA and subsequent ICA within 2 months between 2005 and 2009. Clinical reports were reviewed to identify the indications for referral to ICA. In a subset of 68 patients where non-diagnostic CAC on cCTA and significant stenosis on ICA were present in the same segment, we correlated and analyzed the underlying stenosis severity of the lesion on ICA to the cCTA. Lesions with CAC were analyzed in a standardized fashion by application of reading rules. Results Non-diagnostic CAC on cCTA prompted ICA in 5.6% of patients. CAC occurred at the site of maximum stenosis in segments with stenosis <50% (95.9% [47/49]), 50-69% (82.4% [28/34]), 70-99% (64.5% [31/48]), and 100% (33.3% [1/3]). At the point of maximum calcium deposit, non-obstructive disease was present in 61.2%. Application of reading rules resulted in a 44% reduction in non-diagnostic cCTA reads. Conclusion Severe CAC may prompt further investigation with ICA. There is less CAC with increasing lesion severity at the point of maximum stenosis. Additional application of reading rules improved non-diagnostic cCTA reads.
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Affiliation(s)
- Leif-Christopher Engel
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wai-ee Thai
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hector Medina-Zuluaga
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mihaly Karolyi
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manavjot S Sidhu
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pal Maurovich-Horvat
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ronan Margey
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eugene Pomerantsev
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Suhny Abbara
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gary Y Liew
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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19
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Kim HS, Kim SM, Cha MJ, Kim YN, Kim HJ, Choi JH, Choe YH. Triple rule-out CT angiography protocol with restricting field of view for detection of pulmonary thromboembolism and aortic dissection in emergency department patients: simulation of modified CT protocol for reducing radiation dose. Acta Radiol 2017; 58:521-527. [PMID: 27552981 DOI: 10.1177/0284185116663044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Triple rule-out computed tomography (TRO CT) is a CT protocol designed to simultaneously evaluate the coronary, aorta, and pulmonary arteries. Purpose To evaluate potential diagnostic performance of TRO CT with restricted volume coverage for detection of pulmonary thromboembolism (PTE) and aortic dissection (AD). Material and Methods This study included 1224 consecutive patients with acute chest pain who visited the emergency department and underwent TRO CT using a 128-slice dual-source CT. Image data were reconstructed according to the display field of view (DFOV) of coronary CT angiography (CCTA) and TRO CT protocols in each patient. The presence of PTE and AD was evaluated by independent observers in each DFOV. The radiation dose was calculated to evaluate the potential benefits by restricting z-axis coverage to cardiac scan range instead of the whole thorax. Results Among all patients, 22 cases with PTE (1.9%) and nine cases with AD (0.8%) were found. Except for one PTE case, all cases were detected on both DFOV of TRO CT and CCTA. Mean effective dose for evaluation of entire thorax and cardiac scan coverage were 5.9 ± 1.1 mSv and 3.5 ± 0.7 mSv, respectively. Conclusion Isolated PTE and AD outside the CCTA DFOV rarely occur. Therefore, modified TRO CT protocol using cardiac scan coverage can be adopted to detect PTE and AD with reduced radiation dose.
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Affiliation(s)
- Hyun Su Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Min Jae Cha
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoo Na Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hae Jin Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Ho Choi
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
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20
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The Potential Role of Combined Highly Sensitive Troponin and Coronary Computed Tomography Angiography in the Evaluation of Patients with Suspected Acute Coronary Syndrome in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Duval S, Leroux M, Davienne Y, Brasselet C. [Myocardial ischaemia detection in women]. Ann Cardiol Angeiol (Paris) 2016; 65:433-439. [PMID: 27810095 DOI: 10.1016/j.ancard.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Screening of myocardial ischemia refers to the use of one or more diagnostic tests for coronary heart disease with a dual objective of appropriateness and promptness. In women, as compared to men, the accuracy of the different tests is worse. Thus, to overcome this sex-related penalty, we must define a diagnosis strategy based on risk stratification, enabling the identification of patients requiring invasive investigations. This review discusses various non-invasive diagnostic tests focusing on a female-specific approach and defines the use of numerous diagnostic tests with respect to both risk stratification and symptoms.
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Affiliation(s)
- S Duval
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - M Leroux
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - Y Davienne
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - C Brasselet
- Unité de cardiologie interventionnelle, polyclinique de Courlancy, 38, rue de Courlancy, 51100 Reims, France.
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22
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International Perspectives on Radiology in Preventive Screening. J Am Coll Radiol 2016; 13:1289-1295. [DOI: 10.1016/j.jacr.2016.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 06/04/2016] [Accepted: 06/15/2016] [Indexed: 11/22/2022]
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23
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Ferencik M, Hoffmann U, Bamberg F, Januzzi JL. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. Eur Heart J 2016; 37:2397-405. [PMID: 26843275 PMCID: PMC6279199 DOI: 10.1093/eurheartj/ehw005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/16/2015] [Accepted: 01/05/2016] [Indexed: 02/02/2023] Open
Abstract
The evaluation of patients presenting to the emergency department with suspected acute coronary syndrome (ACS) remains a clinical challenge. The traditional assessment includes clinical risk assessment based on cardiovascular risk factors with serial electrocardiograms and cardiac troponin measurements, often followed by advanced cardiac testing as inpatient or outpatient (i.e. stress testing, imaging). Despite this costly and lengthy work-up, there is a non-negligible rate of missed ACS with an increased risk of death. There is a clinical need for diagnostic strategies that will lead to rapid and reliable triage of patients with suspected ACS. We provide an overview of the evidence for the role of highly sensitive troponin (hsTn) in the rapid and efficient evaluation of suspected ACS. Results of recent research studies have led to the introduction of hsTn with rapid rule-in and rule-out protocols into the guidelines. Highly sensitive troponin increases the sensitivity for the detection of myocardial infarction and decreases time to diagnosis; however, it may decrease the specificity, especially when used as a dichotomous variable, rather than continuous variable as recommended by guidelines; this may increase clinician uncertainty. We summarize the evidence for the use of coronary computed tomography angiography (CTA) as the rapid diagnostic tool in this population when used with conventional troponin assays. Coronary CTA significantly decreases time to diagnosis and discharge in patients with suspected ACS, while being safe. However, it may lead to increase in invasive procedures and includes radiation exposure. Finally, we outline the opportunities for the combined use of hsTn and coronary CTA that may result in increased efficiency, decreased need for imaging, lower cost, and decreased radiation dose.
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Affiliation(s)
- Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, 3180 SW Sam Jackson Park Road, Mail Code UHN62, Portland, OR 97239, USA Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fabian Bamberg
- Department of Radiology, University of Tuebingen, Tuebingen, Germany
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Peña E, Rubens F, Stiell I, Peterson R, Inacio J, Dennie C. Efficiency and safety of coronary CT angiography compared to standard care in the evaluation of patients with acute chest pain: a Canadian study. Emerg Radiol 2016; 23:345-52. [PMID: 27220653 DOI: 10.1007/s10140-016-1407-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
The optimal assessment of patients with chest pain and possible acute coronary syndrome (ACS) remains a diagnostic dilemma for emergency physicians. Cardiac computed tomographic angiography (CCTA) may identify patients who can be safely discharged home from the emergency department (ED). The objective of the study was to compare the efficiency and safety of CCTA to standard care in patients presenting to the ED with low- to intermediate-risk chest pain. This was a single-center before-after study enrolling ED patients with chest pain and low to intermediate risk of ACS, before and after implementing a cardiac CT-based management protocol. The primary outcome was efficiency (time to diagnosis). Secondary outcomes included safety (30-day incidence of major adverse cardiovascular events (MACE)) and length of stay in the ED. We enrolled 258 patients: 130 in the standard care group and 128 in the cardiac CT-based management group. The cardiac CT group had a shorter time to diagnosis of 7.1 h (IQR 5.8-14.0) compared to 532.9 h (IQR 312.8-960.5) for the standard care group (p < 0.0001) but had a longer length of stay in the ED of 7.9 h (IQR 6.5-10.8) versus 5.5 h (IQR 3.9-7.7) (p < 0.0001). The MACE rate was 1.6 % in the standard care group and 0 % in the cardiac CT group. In conclusion, a cardiac CT-based management strategy to rule out ACS in ED patients with low- to intermediate-risk chest pain was safe and led to a shorter time to diagnosis but increased length of stay in the ED.
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Affiliation(s)
- Elena Peña
- Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada.,Department of Radiology, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Fraser Rubens
- Department of Surgery, Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Ian Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada
| | - Rebecca Peterson
- Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada.,Department of Radiology, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Joao Inacio
- Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada.,Department of Radiology, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Carole Dennie
- Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada. .,Department of Radiology, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada.
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Verdini D, Lee AM, Prabhakar AM, Abbara S, Ghoshhajra B. Detection of Cardiac Incidental Findings on Routine Chest CT: The Impact of Dedicated Training in Cardiac Imaging. J Am Coll Radiol 2016; 15:1153-1157. [PMID: 27039002 DOI: 10.1016/j.jacr.2016.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Routine chest CT and cardiac CT angiography (CTA) both image the heart, albeit with different precision and intent. The aim of this study was to evaluate the diagnostic ability of radiologists with different levels of cardiac training to identify cardiac findings on chest CT without electrocardiographic gating compared with a reference standard of electrocardiographically gated cardiac CTA. METHODS Electrocardiographically gated cardiac CT angiographic studies performed between January 2005 to January 2010 in patients with routine chest CT within six months were retrospectively identified. Fourteen radiologists at four stages of training (stage 1, residents with no cardiac training [n = 4]; stage 2, residents who had completed at least one dedicated rotation of cardiac imaging [n = 3]; stage 3, radiologists without cardiac training [n = 3]; and stage 4, radiologists with formal cardiac fellowship training [n = 4]) performed blinded, anonymized cardiac readings of chest CT images. Findings were categorized (coronary arterial, noncoronary vessel, cardiac chamber, myocardial, pericardial, and valve findings) with cardiac CTA as a reference standard. RESULTS Overall, 140 cardiac CT angiographic findings were reported in 63 of 77 patients. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of nongated CTA were 43.6%, 96.8%, 83.0%, 81.6%, and 81.8%, respectively, for all readers. Increasing training was associated with higher sensitivity (30.3%, 35.7%, 45.7%, and 61.2% from stages 1 to 4) but similar specificity (96.4%, 96.7%, 96.3%, and 97.6% from stages 1 to 4). Frequently missed findings categories were coronary arterial, myocardial, and cardiac chamber findings. CONCLUSIONS Increasing cardiac imaging training correlates with increased sensitivity and stable specificity to detect cardiac findings on routine chest CT without electrocardiographic gating. Cardiac findings should be noted on chest CT when observed, and cardiac training should be encouraged.
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Affiliation(s)
- Daniel Verdini
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashley M Lee
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anand M Prabhakar
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Suhny Abbara
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Brian Ghoshhajra
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
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Lee JG, Choi JH, Kim SY, Kim KS, Joo SJ. Psychiatric Characteristics of the Cardiac Outpatients with Chest Pain. Korean Circ J 2016; 46:169-78. [PMID: 27014347 PMCID: PMC4805561 DOI: 10.4070/kcj.2016.46.2.169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/11/2015] [Accepted: 08/10/2015] [Indexed: 12/05/2022] Open
Abstract
Background and Objectives A cardiologist's evaluation of psychiatric symptoms in patients with chest pain is rare. This study aimed to determine the psychiatric characteristics of patients with and without coronary artery disease (CAD) and explore their relationship with the intensity of chest pain. Subjects and Methods Out of 139 consecutive patients referred to the cardiology outpatient department, 31 with atypical chest pain (heartburn, acid regurgitation, dyspnea, and palpitation) were excluded and 108 were enrolled for the present study. The enrolled patients underwent complete numerical rating scale of chest pain and the symptom checklist for minor psychiatric disorders at the time of first outpatient visit. The non-CAD group consisted of patients with a normal stress test, coronary computed tomography angiogram, or coronary angiogram, and the CAD group included those with an abnormal coronary angiogram. Results Nineteen patients (17.6%) were diagnosed with CAD. No differences in the psychiatric characteristics were observed between the groups. "Feeling tense", "self-reproach", and "trouble falling asleep" were more frequently observed in the non-CAD (p=0.007; p=0.046; p=0.044) group. In a multiple linear regression analysis with a stepwise selection, somatization without chest pain in the non-CAD group and hypochondriasis in the CAD group were linearly associated with the intensity of chest pain (β=0.108, R2=0.092, p=0.004; β= -0.525, R2=0.290, p=0.010). Conclusion No differences in psychiatric characteristics were observed between the groups. The intensity of chest pain was linearly associated with somatization without chest pain in the non-CAD group and inversely linearly associated with hypochondriasis in the CAD group.
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Affiliation(s)
- Jea-Geun Lee
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Jeju National University, Jeju, Korea
| | - Joon Hyouk Choi
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Jeju National University, Jeju, Korea
| | - Song-Yi Kim
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Jeju National University, Jeju, Korea
| | - Ki-Seok Kim
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Jeju National University, Jeju, Korea
| | - Seung-Jae Joo
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Jeju National University, Jeju, Korea
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Acute coronary syndrome: evaluation of detection capability using non-electrocardiogram-gated parenchymal phase CT imaging. Jpn J Radiol 2016; 34:331-8. [DOI: 10.1007/s11604-016-0527-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 01/23/2016] [Indexed: 12/20/2022]
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Mahler SA, Riley RF, Russell GB, Hiestand BC, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Bringolf J, Elliott SB, Herrington DM, Burke GL, Miller CD. Adherence to an Accelerated Diagnostic Protocol for Chest Pain: Secondary Analysis of the HEART Pathway Randomized Trial. Acad Emerg Med 2016; 23:70-7. [PMID: 26720295 DOI: 10.1111/acem.12835] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/21/2015] [Accepted: 07/30/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Accelerated diagnostic protocols (ADPs), such as the HEART Pathway, are gaining popularity in emergency departments (EDs) as tools used to risk stratify patients with acute chest pain. However, provider nonadherence may threaten the safety and effectiveness of ADPs. The objective of this study was to determine the frequency and impact of ADP nonadherence. METHODS A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. This trial enrolled 282 adult ED patients with symptoms concerning for acute coronary syndrome without ST-elevation on electrocardiogram. Patients randomized to the HEART Pathway (N = 141) were included in this analysis. Outcomes included index visit disposition, nonadherence, and major adverse cardiac events (MACEs) at 30 days. MACE was defined as death, myocardial infarction, or revascularization. Nonadherence was defined as: 1) undertesting-discharging a high-risk patient from the ED without objective testing (stress testing or coronary angiography) or 2) overtesting-admitting or obtaining objective testing on a low-risk patient. RESULTS Nonadherence to the HEART Pathway occurred in 28 of 141 patients (20%, 95% confidence interval [CI] = 14% to 27%). Overtesting occurred in 19 of 141 patients (13.5%, 95% CI = 8% to 19%) and undertesting in nine of 141 patients (6%, 95% CI = 3% to 12%). None of these 28 patients suffered MACE. The net effect of nonadherence was 10 additional admissions among patients identified as low-risk and appropriate for early discharge (absolute decrease in discharge rate of 7%, 95% CI = 3% to 13%). CONCLUSIONS Real-time use of the HEART Pathway resulted in a nonadherence rate of 20%, mostly due to overtesting. None of these patients had MACE within 30 days. Nonadherence decreased the discharge rate, attenuating the HEART Pathway's impact on health care use.
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Affiliation(s)
- Simon A. Mahler
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Robert F. Riley
- Department of Internal Medicine Division of Cardiology; Wake Forest School of Medicine; Winston-Salem NC
| | - Gregory B. Russell
- Division of Public Health Sciences; Wake Forest School of Medicine; Winston-Salem NC
| | - Brian C. Hiestand
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - James W. Hoekstra
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Cedric W. Lefebvre
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Bret A. Nicks
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - David M. Cline
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Kim L. Askew
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - John Bringolf
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Stephanie B. Elliott
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - David M. Herrington
- Department of Internal Medicine Division of Cardiology; Wake Forest School of Medicine; Winston-Salem NC
| | - Gregory L. Burke
- Division of Public Health Sciences; Wake Forest School of Medicine; Winston-Salem NC
| | - Chadwick D. Miller
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
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Nikolaou N, Arntz H, Bellou A, Beygui F, Bossaert L, Cariou A. Das initiale Management des akuten Koronarsyndroms. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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McKavanagh P, Walls G, McCune C, Malloy J, Harbinson MT, Ball PA, Donnelly PM. The Essentials of Cardiac Computerized Tomography. Cardiol Ther 2015; 4:117-29. [PMID: 26536882 PMCID: PMC4675750 DOI: 10.1007/s40119-015-0052-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Indexed: 10/25/2022] Open
Abstract
Cardiac computerized tomography (CT) has evolved from a research tool to an important diagnostic investigation in cardiology, and is now recommended in European, US, and UK guidelines. This review is designed to give the reader an overview of the current state of cardiac CT. The role of cardiac CT is multifaceted, and includes risk stratification, disease detection, coronary plaque quantification, defining congenital heart disease, planning for structural intervention, and, more recently, assessment of ischemia. This paper addresses basic principles as well as newer evidence.
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Abstract
Although recent advances in noninvasive imaging technologies have potentially improved diagnostic efficiency and clinical outcomes of patients with acute chest pain, controversy remains regarding much of the accumulated evidence. This article reviews the role of coronary computed tomography (CT) angiography in the assessment of coronary risk, and its usefulness in the emergency department in facilitating appropriate disposition decisions. Also discussed is coronary artery calcification incidentally found on CT scans when done for indications such as evaluation of pulmonary embolism or lung cancer. The evidence base and clinical applications for both techniques are described, together with cost-effectiveness and radiation exposure considerations.
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Affiliation(s)
- Swapnesh Parikh
- Internal Medicine Department, Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Matthew J Budoff
- Internal Medicine Department, Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA.
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32
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Nikolaou NI, Arntz HR, Bellou A, Beygui F, Bossaert LL, Cariou A, Danchin N. European Resuscitation Council Guidelines for Resuscitation 2015 Section 8. Initial management of acute coronary syndromes. Resuscitation 2015; 95:264-77. [DOI: 10.1016/j.resuscitation.2015.07.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Lee NJ, Litt H. Cardiac CT angiography for evaluation of acute chest pain. Int J Cardiovasc Imaging 2015; 32:101-12. [PMID: 26342713 DOI: 10.1007/s10554-015-0763-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/31/2015] [Indexed: 01/23/2023]
Abstract
Chest pain is the second most common emergency department (ED) presentation in the United States. Cardiac computed tomography angiography (CCTA) now plays an important role in the evaluation of patients with suspected acute coronary syndrome in the ED setting. In this article, we review the available techniques focused on the use of CCTA to evaluate patients fosr coronary atherosclerosis for timely triage of acute chest pain.
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Affiliation(s)
- Nam Ju Lee
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Harold Litt
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
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Roifman I, Rezai MR, Wijeysundera HC, Chow BJW, Wright GA, Tu JV. Utilization of cardiac computed tomography angiography and outpatient invasive coronary angiography in Ontario, Canada. J Cardiovasc Comput Tomogr 2015; 9:567-71. [PMID: 26233520 DOI: 10.1016/j.jcct.2015.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/06/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiac computed tomography angiography (coronary CTA) has emerged as a non-invasive method of diagnosing coronary artery disease. The extent of utilization and uptake of this technology since initiation of its funding by the government of Ontario is unknown. OBJECTIVES The aim of our study was to examine coronary CTA utilization and the rates of elective invasive coronary angiography and revascularization before and after funding initiation. METHODS We studied all coronary CTAs performed on adults in Ontario after initiation of funding. We also used an interrupted time series analysis to compare the average monthly rates of invasive angiography and revascularization before and after initiation of funding. RESULTS There was an initial steep increase in age-and sex-standardized rates of coronary CTA from 5.0 to 11.4/100,000 over the first two quarters after funding initiation. Afterwards, there was a gradual increase in utilization from 11.4 to 17.1/100,000 over two subsequent calendar years. There was a significant reduction in both the mean monthly outpatient invasive coronary angiography (from 20.7 to 19.9 per 100,000 (p = 0.0004)) and revascularization (from 4.9 to 4.4 per 100,000 (p < 0.0001)) rates in the three years following introduction of the coronary CTA billing code as compared to the three prior to its introduction. CONCLUSIONS Since the introduction of coronary CTA funding in Ontario, there has been a steady and controlled increase in its utilization. The increasing use of coronary CTA was associated with a reduction in both the rates of invasive angiography and revascularization.
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Affiliation(s)
- Idan Roifman
- Institute for Clinical Evaluative Sciences (ICES), Canada; Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Institute for Health Policy, Management and Evaluation (IHPME), Canada
| | | | - Harindra C Wijeysundera
- Institute for Clinical Evaluative Sciences (ICES), Canada; Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Institute for Health Policy, Management and Evaluation (IHPME), Canada
| | - Benjamin J W Chow
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Graham A Wright
- Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Jack V Tu
- Institute for Clinical Evaluative Sciences (ICES), Canada; Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada; Institute for Health Policy, Management and Evaluation (IHPME), Canada.
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Kim HL, Jin KN, Seo JB, Choi YH, Chung WY, Kim SH, Kim MA, Zo JH. The association of brachial-ankle pulse wave velocity with coronary artery disease evaluated by coronary computed tomography angiography. PLoS One 2015; 10:e0123164. [PMID: 25875036 PMCID: PMC4395291 DOI: 10.1371/journal.pone.0123164] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/18/2015] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to investigate whether brachial-ankle pulse wave velocity (baPWV) is associated with the severity of coronary artery disease (CAD) assessed by coronary computed tomography angiography (CCTA), and to evaluate baPWV as a predictor of obstructive CAD on CCTA. A total of 470 patients who underwent both baPWV and CCTA were included. We evaluated stenosis degree and plaque characteristics on CCTA. To estimate the severity of CAD, we calculated the number of segment with plaque (segment involvement score; SIS), stenosis degree-weighted plaque score (segment stenosis score; SSS), and coronary artery calcium score (CACS). The mean baPWV was 1,485 ± 315 cm/s (range, 935-3,175 cm/s). Non-obstructive (stenosis < 50%) and obstructive (stenosis ≥ 50%) CAD was found in 129 patients (27.4%) and 144 (30.6%), respectively. baPWV in patients with obstructive CAD was higher than that of patients with non-obstructive (1,680 ± 396 cm/s versus 1,477 ± 244 cm/s, P < 0.001) or no CAD (1,680 ± 396 cm/s versus ± 196 1,389 cm/s, P < 0.001). baPWV showed significant correlation with SSS (r = 0.429, P < 0.001), SIS (r = 0.395, P < 0.001), CACS (r 0.346, P < 0.001), and the number of segment with non-calcified plaque (r 0.092, P = 0.047), mixed plaque (r = 0.267, P < 0.001), and calcified plaque (r = 0.348, P < 0.001), respectively. The optimal baPWV cut-off value for the detection of obstructive CAD was 1,547 cm/s. baPWV ≥ 1,547 cm/s was independent predictor for the obstructive CAD. In conclusion, baPWV is well correlated with the severity of CAD evaluated by CCTA. baPWV has the potential to predict severity of coronary artery atherosclerosis.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Nam Jin
- Department of Radiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Bin Seo
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Choi
- Department of Radiology, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Woo-Young Chung
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Myung-A Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Joo-Hee Zo
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
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Mahler SA, Miller CD, Litt HI, Gatsonis CA, Snyder BS, Hollander JE. Performance of the 2-hour accelerated diagnostic protocol within the American College of Radiology Imaging Network PA 4005 cohort. Acad Emerg Med 2015; 22:452-60. [PMID: 25810343 DOI: 10.1111/acem.12621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/15/2014] [Accepted: 11/12/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The 2-hour accelerated diagnostic protocol (ADAPT) is a decision rule designed to identify emergency department (ED) patients with chest pain for early discharge. Previous studies in the Asia-Pacific region demonstrated high sensitivity (97.9% to 99.7%) for major adverse cardiac events (MACE) at 30 days. The objective of this study was to determine the validity of ADAPT for risk stratification in a cohort of U.S. ED patients with suspected acute coronary syndrome (ACS). METHODS A secondary analysis of participants enrolled in the American College of Radiology Imaging Network (ACRIN) PA 4005 trial was conducted. This trial enrolled 1,369 patients at least 30 years old with symptoms suggestive of ACS. All data elements were collected prospectively at the time of enrollment. Each patient was classified as low risk or at risk by ADAPT. Early discharge rate and sensitivity for MACE, defined as cardiac death, myocardial infarction (MI), or coronary revascularization at 30 days, were calculated. RESULTS Of 1,140 patients with complete biomarker data, MACE occurred in 31 patients (2.7%). Among 551 of the 1,140 (48.3%, 95% confidence interval [CI] = 45.4% to 51.3%), ADAPT identified for early discharge; five of the 551 (0.9%, 95% CI = 0.3% to 2.1%) had MACE at 30 days. ADAPT was 83.9% (95% CI = 66.3% to 94.5%) sensitive, identifying 26 of 31 patients with MACE. Of the five patients identified for early discharge by ADAPT with MACE, there were no deaths, one patient with MI, and five with revascularizations. CONCLUSIONS In this first North American application of the ADAPT strategy, sensitivity for MACE within 30 days was 83.9%. One missed adverse event was a MI, with the remainder representing coronary revascularizations. The effect of missing revascularization events needs further investigation.
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Affiliation(s)
- Simon A. Mahler
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Chadwick D. Miller
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Harold I. Litt
- Department of Radiology; Perelman School of Medicine of the University of Pennsylvania; Philadelphia PA
| | - Constantine A. Gatsonis
- Center for Statistical Sciences; Brown University School of Public Health; Providence RI
- Department of Biostatistics; Brown University School of Public Health; Providence RI
| | - Bradley S. Snyder
- Center for Statistical Sciences; Brown University School of Public Health; Providence RI
| | - Judd E. Hollander
- Department of Emergency Medicine; Perelman School of Medicine of the University of Pennsylvania; Philadelphia PA
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Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM, Burke GL, Miller CD. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 2015; 8:195-203. [PMID: 25737484 DOI: 10.1161/circoutcomes.114.001384] [Citation(s) in RCA: 294] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care. METHODS AND RESULTS Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%-9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days. CONCLUSIONS The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01665521.
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Affiliation(s)
- Simon A Mahler
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Robert F Riley
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory B Russell
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - James W Hoekstra
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Cedric W Lefebvre
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Bret A Nicks
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Cline
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kim L Askew
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Stephanie B Elliott
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Herrington
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory L Burke
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Chadwick D Miller
- From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
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Eck BL, Fahmi R, Fuqua C, Vembar M, Dhanantwari A, Bezerra HG, Wilson DL. Low dose dynamic myocardial CT perfusion using advanced iterative reconstruction. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2015; 9417:94170Z. [PMID: 32210494 PMCID: PMC7093059 DOI: 10.1117/12.2081418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Dynamic myocardial CT perfusion (CTP) can provide quantitative functional information for the assessment of coronary artery disease. However, x-ray dose in dynamic CTP is high, typically from 10mSv to >20mSv. We compared the dose reduction potential of advanced iterative reconstruction, Iterative Model Reconstruction (IMR, Philips Healthcare, Cleveland, Ohio) to hybrid iterative reconstruction (iDose4) and filtered back projection (FBP). Dynamic CTP scans were obtained using a porcine model with balloon-induced ischemia in the left anterior descending coronary artery to prescribed fractional flow reserve values. High dose dynamic CTP scans were acquired at 100kVp/100mAs with effective dose of 23mSv. Low dose scans at 75mAs, 50mAs, and 25mAs were simulated by adding x-ray quantum noise and detector electronic noise to the projection space data. Images were reconstructed with FBP, iDose4, and IMR at each dose level. Image quality in static CTP images was assessed by SNR and CNR. Blood flow was obtained using a dynamic CTP analysis pipeline and blood flow image quality was assessed using flow-SNR and flow-CNR. IMR showed highest static image quality according to SNR and CNR. Blood flow in FBP was increasingly over-estimated at reduced dose. Flow was more consistent for iDose4 from 100mAs to 50mAs, but was over-estimated at 25mAs. IMR was most consistent from 100mAs to 25mAs. Static images and flow maps for 100mAs FBP, 50mAs iDose4, and 25mAs IMR showed comparable, clear ischemia, CNR, and flow-CNR values. These results suggest that IMR can enable dynamic CTP at significantly reduced dose, at 5.8mSv or 25% of the comparable 23mSv FBP protocol.
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Affiliation(s)
- Brendan L Eck
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Rachid Fahmi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Christopher Fuqua
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Mani Vembar
- Philips Healthcare, Cleveland, OH 44143, USA
| | | | - Hiram G Bezerra
- Cardiovascular Imaging Core Laboratory, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA
| | - David L Wilson
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
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Miura K, Kato M, Dote K, Kagawa E, Nakano Y, Oda N, Sasaki S. Association of nonculprit plaque characteristics with transient slow flow phenomenon during percutaneous coronary intervention. Int J Cardiol 2015; 181:108-13. [DOI: 10.1016/j.ijcard.2014.11.218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 01/02/2023]
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Garcia MJ. Computed Tomographic Angiography (CTA) of the Coronary, Aorta, Visceral, and Lower Extremity Arteries. PANVASCULAR MEDICINE 2015:1225-1248. [DOI: 10.1007/978-3-642-37078-6_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Barone-Rochette G, Jankowski A, Rodiere M. Apport de l’IRM et du scanner cardiaque en pratique clinique courante. Rev Med Interne 2014; 35:742-51. [DOI: 10.1016/j.revmed.2014.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 05/07/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
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Parisi R, Mirabella F, Secco GG, Fattori R. Multimodality imaging in apical hypertrophic cardiomyopathy. World J Cardiol 2014; 6:916-23. [PMID: 25276293 PMCID: PMC4176801 DOI: 10.4330/wjc.v6.i9.916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/02/2014] [Accepted: 07/15/2014] [Indexed: 02/06/2023] Open
Abstract
Apical hypertrophic cardiomyopathy (AHCM) is a relatively rare morphologic variant of HCM in which the hypertrophy of myocardium is localized to the left ventricular apex. Symptoms of AHCM might vary from none to others mimic coronary artery disease including acute coronary syndrome, thus resulting in inappropriate hospitalization. Transthoracic echocardiography is the first-line imaging technique for the diagnosis of hypertrophic cardiomyopathies. However, when the hypertrophy of the myocardium is localized in the ventricular apex might results in missed diagnosis. Aim of this paper is to review the different imaging techniques used for the diagnosis of AHCM and their role in the detection and comprehension of this uncommon disease.
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Affiliation(s)
- Rosario Parisi
- Rosario Parisi, Francesca Mirabella, Gioel Gabrio Secco, Rossella Fattori, Interventional Cardiology, AO Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy
| | - Francesca Mirabella
- Rosario Parisi, Francesca Mirabella, Gioel Gabrio Secco, Rossella Fattori, Interventional Cardiology, AO Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy
| | - Gioel Gabrio Secco
- Rosario Parisi, Francesca Mirabella, Gioel Gabrio Secco, Rossella Fattori, Interventional Cardiology, AO Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy
| | - Rossella Fattori
- Rosario Parisi, Francesca Mirabella, Gioel Gabrio Secco, Rossella Fattori, Interventional Cardiology, AO Ospedali Riuniti Marche Nord, 61121 Pesaro, Italy
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Nagori M, Narain VS, Saran RK, Dwivedi SK, Sethi R. Efficacy of multi-detector coronary computed tomography angiography in comparison with exercise electrocardiogram in the triage of patients of low risk acute chest pain. Indian Heart J 2014; 66:435-42. [PMID: 25173203 PMCID: PMC4150036 DOI: 10.1016/j.ihj.2014.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 05/18/2014] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To compare the safety and diagnostic efficacy of coronary computed tomography angiography (CTA) with exercise electrocardiography (XECG) in triaging patients of low risk acute chest pain. BACKGROUND Noninvasive assessment of coronary stenosis by CTA may improve early and accurate triage of patients presenting with acute chest pain to the emergency department (ED). METHODS Low risk patients of possible acute coronary syndrome (ACS) were included in the study. The patients in CTA arm with significant stenosis (≥ 50%) underwent catheterization, while those with no or intermediate stenosis (<50%) were discharged from ED and followed up periodically for six months for major adverse cardiovascular events (MACE). The same protocol was applied for XECG arm. Outcomes included: safety and diagnostic efficacy. RESULTS A total of 81 (41 CTA and 40 XECG) patients were enrolled. In this study CTA was observed to be 100% sensitive and 95.7% specific in diagnosing MACE in low risk patients of chest pain presenting to the ED, with a PPV of 94.7% and an NPV of 100%.The overall diagnostic efficacy was 97.6%. XECG was observed to be 72.7% sensitive and 96.6% specific in diagnosing MACE with a PPV of 88.9% and NPV of 90.3% in low risk chest pain patients presenting to the ED. The overall diagnostic accuracy was 90%. CONCLUSION CTA is an excellent diagnostic tool in ED patients with low risk of ACS, with minimum time delay as compared to XECG, and also is safe for triaging such patients.
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Affiliation(s)
- M Nagori
- Department of Cardiology, KGMU, LKO, UP, India.
| | - V S Narain
- Department of Cardiology, KGMU, LKO, UP, India
| | - R K Saran
- Department of Cardiology, KGMU, LKO, UP, India
| | - S K Dwivedi
- Department of Cardiology, KGMU, LKO, UP, India
| | - R Sethi
- Department of Cardiology, KGMU, LKO, UP, India
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Dave DM, Ferencic M, Hoffmann U, Udelson JE. Imaging techniques for the assessment of suspected acute coronary syndromes in the emergency department. Curr Probl Cardiol 2014; 39:191-247. [PMID: 24952880 PMCID: PMC8323766 DOI: 10.1016/j.cpcardiol.2014.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Garrett KG, De Cecco CN, Schoepf UJ, Silverman JR, Krazinski AW, Geyer LL, Lewis AJ, Headden GF, Ravenel JG, Suranyi P, Meinel FG. Residents' performance in the interpretation of on-call "triple-rule-out" CT studies in patients with acute chest pain. Acad Radiol 2014; 21:938-44. [PMID: 24928163 DOI: 10.1016/j.acra.2014.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/25/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate the performance of radiology residents in the interpretation of on-call, emergency "triple-rule-out" (TRO) computed tomographic (CT) studies in patients with acute chest pain. MATERIALS AND METHODS The study was institutional review board-approved and Health Insurance Portability and Accountability Act compliant. Data from 617 on-call TRO studies were analyzed. Dedicated software enables subspecialty attendings to grade discrepancies in interpretation between preliminary trainee reports and their final interpretation as "unlikely to be significant" (minor discrepancies) or "likely to be significant" for patient management (major discrepancies). The frequency of minor, major and all discrepancies in resident's TRO interpretations was compared to 609 emergent non-electrocardiography (ECG)-synchronized chest CT studies using Pearson χ(2) test. RESULTS Minor discrepancies occurred more often in the TRO group (9.1% vs. 3.9%, P < .001), but there was no difference in the frequency of major discrepancies (2.1% vs. 2.8%, P = .55). Minor discrepancies in the TRO group most commonly resulted from missed extrathoracic findings with missed liver lesions being the most frequent. Major discrepancies mostly encompassed cardiac and extracardiac vascular findings but did not result in unnecessary interventions, significant immediate changes in management, or adverse patient outcomes. CONCLUSIONS On-call resident interpretation of TRO CT studies in patients with acute chest pain is congruent with final subspecialty attending interpretation in the overwhelming majority of cases. The rate of discrepancies likely to affect patient management in this domain is not different from emergent non-ECG-synchronized chest CT.
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Zeb I, Abbas N, Nasir K, Budoff MJ. Coronary computed tomography as a cost–effective test strategy for coronary artery disease assessment – A systematic review. Atherosclerosis 2014; 234:426-35. [DOI: 10.1016/j.atherosclerosis.2014.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 02/10/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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Jiang B, Wang J, Lv X, Cai W. Dual-source CT versus single-source 64-section CT angiography for coronary artery disease: A meta-analysis. Clin Radiol 2014; 69:861-9. [PMID: 24854029 DOI: 10.1016/j.crad.2014.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 03/26/2014] [Accepted: 03/31/2014] [Indexed: 01/14/2023]
Abstract
AIM To perform a meta-analysis to compare the diagnostic performance of single-source 64-section computed tomography (CT) versus dual-source CT angiography for diagnosis of coronary artery disease (CAD). MATERIALS AND METHODS The Cochrane Library, MEDLINE, and EMBASE were searched for relevant original papers. Inclusion criteria were (1) significant CAD defined as ≥50% reduction in luminal diameter by invasive coronary angiography as reference standard; (2) single-source 64-section CT or dual-source CT was used; (3) results were reported in absolute numbers of true-positive, false-positive, true-negative, and false-negative results or sufficiently detailed data for deriving these numbers were presented. A random-effects model was used for the meta-analysis. RESULTS Fifty-one papers including 3966 patients who underwent single-source 64-section CT and 2047 patients who underwent dual-source CT at a per-patient level were pooled. The diagnostic values of single-source 64-section CT versus dual-source CT were 97% versus 97% for sensitivity (p = 0.386), 78% versus 86% for specificity (p < 0.001), 90% versus 85% for positive predictive value (PPV; p < 0.001), 93% versus 97% for negative predictive value (NPV; p = 0.001), 6.8 versus 6.5 for positive likelihood ratio (p = 0.018), 0.04 versus 0.04 for negative likelihood ratio (p = 0.625), and 191.59 versus 207.37 for diagnostic odds ratio (p = 0.043), respectively. CONCLUSION Dual-source CT and single-source 64-section CT have similar negative likelihood ratios and, therefore, there was no significant difference in their utility to rule out CAD in intermediate-risk patients. However, compared to single-source 64-section CT, dual-source CT has significantly higher specificity, so that CT-based decisions for subsequent coronary catheter angiography are more accurate.
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Affiliation(s)
- B Jiang
- Department of Radiology, BenQ Medical Center, Nanjing Medical University, 71 Hexi Street, Jianye District, Nanjing 210019, China
| | - J Wang
- Department of Radiology, BenQ Medical Center, Nanjing Medical University, 71 Hexi Street, Jianye District, Nanjing 210019, China.
| | - X Lv
- Department of Interventional Radiology, BenQ Medical Center, Nanjing Medical University, 71 Hexi Street, Jianye District, Nanjing 210019, China
| | - W Cai
- Department of Cardiology, BenQ Medical Center, Nanjing Medical University, 71 Hexi Street, Jianye District, Nanjing 210019, China
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Karius P, Schuetz GM, Schlattmann P, Dewey M. Extracardiac findings on coronary CT angiography: A systematic review. J Cardiovasc Comput Tomogr 2014; 8:174-82.e1-6. [DOI: 10.1016/j.jcct.2014.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/03/2014] [Accepted: 04/09/2014] [Indexed: 12/21/2022]
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The evolution and investigation of native coronary arteries in patients after coronary stent implantation: a study by 320-detector CT angiography. Int J Cardiovasc Imaging 2014; 30 Suppl 1:13-24. [PMID: 24715437 DOI: 10.1007/s10554-014-0417-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
Abstract
To study the role of 320-detector coronary computed tomography angiography (CTA) in assessing native coronary arteries in patients treated with coronary stents. 123 patients with coronary stenting received both CTA and conventional coronary angiography (CCA) within 1 day. The clinical parameters, coronary calcium scoring, CTA and CCA were analyzed to determine the prevalence of significant stenosis of native coronary arteries (SSNCA), the predictive value of CTA and the factors correlating with SSNCA and newly developed SSNCA after stenting (NDSSNCAS), with CCA as the standard of reference, using both vessel-based analysis (VBA) and patient-based analysis (PBA). Both the source and the reconstructed images were analyzed by CTA. All native coronary arteries were interpretable independent of cardiac motion. CTA showed a sensitivity/specificity of 93.5%/97.3% and 92.5%/92.5% in diagnosing SSNCA in VBA and PBA, respectively. The significant factors related to SSNCA were higher calcium scores (P = 0.003), a higher serum glucose level (P = 0.048), a greater number of vessels without previous stent placement (P = 0.003) and fewer stents implanted within the vessels (P = 0.003). The risk factors showed no significant correlation from PBA on SSNCA or from NDSSNCAS on either VBA or PBA. CTA demonstrates excellent correlation with CCA. The prevalence of SSNCA is significantly correlated with the presence of higher calcium scores in the arteries, a higher serum glucose level, a greater number of vessels without previous stent placement and fewer stents implanted within the vessels; PBA on SSNCA and NDSSNCAS on both VBA and PBA showed no significance.
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