Surgical Unroofing of Hemodynamically Significant Left Anterior Descending Myocardial Bridges. Annals of thoracic surgery 2016
Left anterior descending artery myocardial bridges (MBs) range from clinically insignificant incidental angiographic findings to a potential cause of sudden cardiac death. Within this spectrum, a group of patients with isolated, symptomatic, and hemodynamically significant MBs despite maximally tolerated medical therapy exist for whom the optimal treatment is controversial. We evaluated supraarterial myotomy, or surgical unroofing, of the left anterior descending MBs as an isolated procedure in these patients.In 50 adult patients, we prospectively evaluated baseline clinical characteristics, risk factors, and medications for coronary artery disease, relevant diagnostic data (stress echocardiography, computed tomography angiography, stress coronary angiogram with dobutamine challenge for measurement of diastolic fractional flow reserve, and intravascular ultrasonography), and anginal symptoms using the Seattle Angina Questionnaire. These patients then underwent surgical unroofing of their left anterior descending artery MBs followed by readministration of the Seattle Angina Questionnaire at 6.6-month (range, 2 to 13) follow-up after surgery.Dramatic improvements were noted in physical limitation due to angina (52.0 versus 87.1, p < 0.001), anginal stability (29.6 versus 66.4, p < 0.001), anginal frequency (52.1 versus 84.7, p < 0.001), treatment satisfaction (76.1 versus 93.9, p < 0.001), and quality of life (25.0 versus 78.9, p < 0.001), all five dimensions of the Seattle Angina Questionnaire. There were no major complications or deaths.Surgical unroofing of carefully selected patients with MBs can be performed safely as an independent procedure with significant improvement in symptoms postoperatively. It is the optimal treatment for isolated, symptomatic, and hemodynamically significant MBs resistant to maximally tolerated medical therapy.
View details for DOI 10.1016/j.athoracsur.2016.08.035
View details for PubMedID 27745841
Surgical Repair of 115 Patients With Anomalous Aortic Origin of a Coronary Artery From a Single Institution. World journal for pediatric & congenital heart surgery 2016; 7 (3): 353-359
Anomalous aortic origin of a coronary artery (AAOCA) has been associated with myocardial ischemia and sudden death. The past decade has provided important insights into the natural history and typical patterns of presentation. However, there are also a number of unresolved controversies regarding the indications for surgery and the efficacy of that surgery. The purpose of this study was to review our surgical experience with AAOCA in 115 patients at a single institution.One hundred and fifteen patients have undergone surgical repair of AAOCA at our institution. There were 82 males and 33 females, and the median age at surgery was 16 years. Fifty-nine patients had preoperative symptoms of myocardial ischemia, including 56 with exertional chest pain or syncope and 3 sudden death events. Twenty-four patients had associated congenital heart defects. Seven patients had an associated myocardial bridge.Surgical repair was accomplished by unroofing of an intramural coronary in 86, reimplantation in 9, and pulmonary artery translocation in 20. There has been no early or late mortality. Fifty-seven (97%) of the 59 symptomatic patients have been free of any cardiac symptoms postoperatively. Two patients had recurrent symptoms and underwent reoperation (one had revision of the initial repair and one had repair of a myocardial bridge).Surgical repair of AAOCA can be safely performed and is highly efficacious in relieving symptoms of myocardial ischemia. The two "surgical failures" in this series had an anatomic basis and underscore the need to reassess both the proximal and distal anatomy in these patients.
View details for DOI 10.1177/2150135116641892
View details for PubMedID 27142404
Bilateral Giant Coronary Artery Aneurysms Complicated by Acute Coronary Syndrome and Cardiogenic Shock. Annals of thoracic surgery 2016; 101 (4): e95-7
Giant coronary aneurysms are rare. We present a 25-year-old woman with a known history of non-Kawasaki/nonatherosclerotic bilateral coronary aneurysms. She was transferred to our facility with acute coronary syndrome complicated by cardiogenic shock. Angiography demonstrated giant bilateral coronary aneurysms and complete occlusion of the left anterior descending (LAD) artery. Emergent coronary artery bypass grafting was performed. Coronary artery bypass grafting is the preferred approach for addressing giant coronary aneurysms. Intervention on the aneurysm varies in the literature. Aggressive revascularization is recommended in the non-Kawasaki/nonatherosclerotic aneurysm patient, and ligation should be performed in patients with thromboembolic phenomena.
View details for DOI 10.1016/j.athoracsur.2015.06.104
View details for PubMedID 27000621
Exercise Strain Echocardiography in Patients With a Hemodynamically Significant Myocardial Bridge Assessed by Physiological Study. Journal of the American Heart Association 2015; 4 (11)
Although a myocardial bridge (MB) is often regarded as a benign coronary variant, recent studies have associated MB with focal myocardial ischemia. The physiological consequences of MB on ventricular function during stress have not been well established.We enrolled 58 patients with MB of the left anterior descending artery, diagnosed by intravascular ultrasound. Patients underwent invasive physiological evaluation of the MB by diastolic fractional flow reserve during dobutamine challenge and exercise echocardiography. Septal and lateral longitudinal strain (LS) were assessed at rest and immediately after exercise and compared with strain of matched controls. Absolute and relative changes in strain were also calculated. The mean age was 42.516.0 years. Fifty-five patients had a diastolic fractional flow reserve 0.76. At rest, there was no significant difference between the 2 groups in septal LS (19.01.8% for patients with MB versus 19.21.5% for control, P=0.53) and lateral LS (20.12.0% versus 20.01.6%, P=0.83). With stress, compared with controls, patients with MB had a lower peak septal LS (18.92.6% versus 21.71.6%, P<0.001) and lower absolute (-0.12.1% versus 2.51.3%, P<0.001) and relative change (-0.611.2% versus 13.17.8%, P<0.001) in septal LS, whereas there was no significant difference in lateral LS. In multivariate analysis, diastolic fractional flow reserve and length were independent determinants of lower changes in septal LS.Patients with a hemodynamically significant MB, determined by invasive diastolic fractional flow reserve, have significantly lower change in septal LS on exercise echocardiography, suggesting that septal LS may be useful for noninvasively assessing the hemodynamic significance of an MB.
View details for DOI 10.1161/JAHA.115.002496
View details for PubMedID 26581225
Presence of plaques predicts worse outcomes in multi-detector computed tomography in patients with stable chest pain syndrome INTERNATIONAL JOURNAL OF CARDIOLOGY 2014; 173 (3): 570-572
Cost and Resource Utilization Associated With Use of Computed Tomography to Evaluate Chest Pain in the Emergency Department The Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) Study CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2013; 6 (5): 514-524
Coronary computed tomographic angiography (cCTA) allows rapid, noninvasive exclusion of obstructive coronary artery disease (CAD). However, concern exists whether implementation of cCTA in the assessment of patients presenting to the emergency department with acute chest pain will lead to increased downstream testing and costs compared with alternative strategies. Our aim was to compare observed actual costs of usual care (UC) with projected costs of a strategy including early cCTA in the evaluation of patients with acute chest pain in the Rule Out Myocardial Infarction Using Computer Assisted Tomography I (ROMICAT I) study.We compared cost and hospital length of stay of UC observed among 368 patients enrolled in the ROMICAT I study with projected costs of management based on cCTA. Costs of UC were determined by an electronic cost accounting system. Notably, UC was not influenced by cCTA results because patients and caregivers were blinded to the cCTA results. Costs after early implementation of cCTA were estimated assuming changes in management based on cCTA findings of the presence and severity of CAD. Sensitivity analysis was used to test the influence of key variables on both outcomes and costs. We determined that in comparison with UC, cCTA-guided triage, whereby patients with no CAD are discharged, could reduce total hospital costs by 23% (P<0.001). However, when the prevalence of obstructive CAD increases, index hospitalization cost increases such that when the prevalence of 50% stenosis is >28% to 33%, the use of cCTA becomes more costly than UC.cCTA may be a cost-saving tool in acute chest pain populations that have a prevalence of potentially obstructive CAD <30%. However, increased cost would be anticipated in populations with higher prevalence of disease.
View details for DOI 10.1161/CIRCOUTCOMES.113.000244
View details for Web of Science ID 000324526400005
View details for PubMedID 24021693
Distribution, Determinants, and Normal Reference Values of Thoracic and Abdominal Aortic Diameters by Computed Tomography (from the Framingham Heart Study). American journal of cardiology 2013; 111 (10): 1510-1516
Current screening and detection of asymptomatic aortic aneurysms is based largely on uniform cut-point diameters. The aims of this study were to define normal aortic diameters in asymptomatic men and women in a community-based cohort and to determine the association between aortic diameters and traditional risk factors for cardiovascular disease. Measurements of the diameters of the ascending thoracic aorta (AA), descending thoracic aorta (DTA), infrarenal abdominal aorta (IRA), and lower abdominal aorta (LAA) were acquired from 3,431 Framingham Heart Study (FHS) participants. Mean diameters were stratified by gender, age, and body surface area. Univariate associations with risk factor levels were examined, and multivariate linear regression analysis was used to assess the significance of covariate-adjusted relations with aortic diameters. For men, the average diameters were 34.1 mm for the AA, 25.8 mm for the DTA, 19.3 mm for the IRA, and 18.7mm for the LAA. For women, the average diameters were 31.9 mm for the AA, 23.1mm for the DTA, 16.7 mm for the IRA, and 16.0 mm for the LAA. The mean aortic diameters were strongly correlated (p <0.0001) with age and body surface area in age-adjusted analyses, and these relations remained significant in multivariate regression analyses. Positive associations of diastolic blood pressure with AA and DTA diameters in both genders and pack-years of cigarette smoking with DTA diameter in women and IRA diameter in men and women were observed. In conclusion, average diameters of the thoracic and abdominal aorta by computed tomography are larger in men compared with women, vary significantly with age and body surface area, and are associated with modifiable cardiovascular disease risk factors, including diastolic blood pressure and cigarette smoking.
View details for DOI 10.1016/j.amjcard.2013.01.306
View details for PubMedID 23497775
A novel stress echocardiography pattern for myocardial bridge with invasive structural and hemodynamic correlation. Journal of the American Heart Association 2013; 2 (2)
Patients with a myocardial bridge (MB) and no significant obstructive coronary artery disease (CAD) may experience angina presumably from ischemia, but noninvasive assessment has been limited and the underlying mechanism poorly understood. This study seeks to correlate a novel exercise echocardiography (EE) finding for MBs with invasive structural and hemodynamic measurements.Eighteen patients with angina and an EE pattern of focal end-systolic to early-diastolic buckling in the septum with apical sparing were prospectively enrolled for invasive assessment. This included coronary angiography, left anterior descending artery (LAD) intravascular ultrasound (IVUS), and intracoronary pressure and Doppler measurements at rest and during dobutamine stress. All patients were found to have an LAD MB on IVUS. The ratios of diastolic intracoronary pressure divided by aortic pressure at rest (Pd/Pa) and during dobutamine stress (diastolic fractional flow reserve [dFFR]) and peak Doppler flow velocity recordings at rest and with stress were successfully performed in 14 patients. All had abnormal dFFR (0.75) at stress within the bridge, distally or in both positions, and on average showed a more than doubling in peak Doppler flow velocity inside the MB at stress. Seventy-five percent of patients had normalization of dFFR distal to the MB, with partial pressure recovery and a decrease in peak Doppler flow velocity.A distinctive septal wall motion abnormality with apical sparing on EE is associated with a documented MB by IVUS and a decreased dFFR. We posit that the septal wall motion abnormality on EE is due to dynamic ischemia local to the compressed segment of the LAD from the increase in velocity and decrease in perfusion pressure, consistent with the Venturi effect.
View details for DOI 10.1161/JAHA.113.000097
View details for PubMedID 23591827
Resequencing and Clinical Associations of the 9p21.3 Region A Comprehensive Investigation in the Framingham Heart Study CIRCULATION 2013; 127 (7): 799-810
9p21.3 is among the most strongly replicated regions for cardiovascular disease. There are few reports of sequencing the associated 9p21.3 interval. We set out to sequence the 9p21.3 region followed by a comprehensive study of genetic associations with clinical and subclinical cardiovascular disease and its risk factors, as well as with copy number variation and gene expression, in the Framingham Heart Study (FHS).We sequenced 281 individuals (94 with myocardial infarction, 94 with high coronary artery calcium levels, and 93 control subjects free of elevated coronary artery calcium or myocardial infarction), followed by genotyping and association in >7000 additional FHS individuals. We assessed genetic associations with clinical and subclinical cardiovascular disease, risk factor phenotypes, and gene expression levels of the protein-coding genes CDKN2A and CDKN2B and the noncoding gene ANRIL in freshly harvested leukocytes and platelets. Within this large sample, we found strong associations of 9p21.3 variants with increased risk for myocardial infarction, higher coronary artery calcium levels, and larger abdominal aorta diameters and no evidence for association with traditional cardiovascular disease risk factors. No common protein-coding variation, variants in splice donor or acceptor sites, or copy number variation events were observed. By contrast, strong associations were observed between genetic variants and gene expression, particularly for a short isoform of ANRIL and for CDKN2B.Our thorough genomic characterization of 9p21.3 suggests common variants likely account for observed disease associations and provides further support for the hypothesis that complex regulatory variation affecting ANRIL and CDKN2B gene expression may contribute to increased risk for clinically apparent and subclinical coronary artery disease and aortic disease.
View details for DOI 10.1161/CIRCULATIONAHA.112.111559
View details for Web of Science ID 000315302200017
View details for PubMedID 23315372
Single Resting hsTnT Level Predicts Abnormal Myocardial Stress Test in Acute Chest Pain Patients With Normal Initial Standard Troponin JACC-CARDIOVASCULAR IMAGING 2013; 6 (1): 72-82
The goal of this study was to determine the ability of a single, resting high-sensitivity troponin T (hsTnT) measurement to predict abnormal myocardial perfusion imaging (MPI) in patients presenting with acute chest pain to the emergency department (ED).HsTnT assays precisely detect very low levels of troponin T, which may be a surrogate for the presence and extent of myocardial ischemia.We included all patients from the ROMICAT I (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial, an observational cohort study, who underwent both single-photon emission computed tomography (SPECT)-MPI stress testing and 64-slice computed tomography angiography (CTA) and in whom hsTnT measurements were available. We assessed the discriminatory value of hsTnT for abnormal SPECT-MPI and the association of reversible myocardial ischemia by SPECT-MPI and the extent of coronary atherosclerosis by CTA to hsTnT levels.Of the 138 patients (mean age 54 11 years, 46% male), 19 (13.7%) had abnormal SPECT-MPI. Median hsTnT levels were significantly different between patients with normal and abnormal SPECT-MPI (9.41 pg/ml [interquartile range (IQR): 5.73 to 19.20 pg/ml] vs. 4.89 pg/ml [IQR: 2.34 to 7.68 pg/ml], p = 0.001). Sensitivity of 80% and 90% to detect abnormal SPECT-MPI was reached at hsTnT levels as low as 5.73 and 4.26 pg/ml, respectively. Corresponding specificity was 62% and 46%, and negative predictive value was 96% and 96%, respectively. HsTnT levels had good discriminatory ability for prediction of abnormal SPECT-MPI (area under the curve: 0.739, 95% confidence interval: 0.609 to 0.868). Both reversible myocardial ischemia and the extent of coronary atherosclerosis (combined model r(2) = 0.19 with partial of r(2) = 0.12 and r(2) = 0.05, respectively) independently and incrementally predicted the measured hsTnT levels.In patients with acute chest pain, myocardial perfusion abnormalities and coronary artery disease are predicted by resting hsTnT levels. Prospective evaluations are warranted to confirm whether resting hsTnT could serve as a powerful triage tool in chest pain patients in the ED before diagnostic testing and improve the effectiveness of patient management.
View details for DOI 10.1016/j.jcmg.2012.08.014
View details for Web of Science ID 000314581600011
View details for PubMedID 23328564
Periaortic adipose tissue and aortic dimensions in the Framingham Heart Study. Journal of the American Heart Association 2012; 1 (6)
Periaortic fat, because of its contiguity with the aorta, may promote vascular remodeling and aortic dilatation. However, the relations between perioartic fat depots and aortic dimensions have not been previously described.A total of 3001 individuals (mean age 50 10 years, 49% women) from the Framingham Offspring and Third Generation cohorts underwent computed tomography for quantification of periaortic fat and aortic dimensions. We estimated the association between quantitative periaortic and visceral adipose tissue volumes (per standard deviation [SD] increment of volume) with aortic dimensions in both the thorax and abdomen. Thoracic periaortic fat was associated with higher thoracic aortic dimensions (? coefficient per SD of fat volume 0.67 mm, 95% confidence interval 0.58 to 0.76 mm; P<0.001). The association persisted after adjustment for age, sex, and cardiovascular risk factors including body mass index and visceral adipose tissue volume. Results for the association of periaortic fat and abdominal aortic dimensions were similar. Further adjustment for adipokines (resistin and adiponectin) had no significant impact on these associations.Periaortic fat volume was associated with aortic dimensions in both the thorax and abdomen, supporting the notion that local fat depots may contribute to aortic remodeling. Further work to understand the mechanisms underlying this association is warranted.
View details for DOI 10.1161/JAHA.112.000885
View details for PubMedID 23316310
Comparison of Traditional Cardiovascular Risk Models and Coronary Atherosclerotic Plaque as Detected by Computed Tomography for Prediction of Acute Coronary Syndrome in Patients With Acute Chest Pain ACADEMIC EMERGENCY MEDICINE 2012; 19 (8): 934-942
The objective was to determine the association of four clinical risk scores and coronary plaque burden as detected by computed tomography (CT) with the outcome of acute coronary syndrome (ACS) in patients with acute chest pain. The hypothesis was that the combination of risk scores and plaque burden improved the discriminatory capacity for the diagnosis of ACS.The study was a subanalysis of the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial-a prospective observational cohort study. The authors enrolled patients presenting to the emergency department (ED) with a chief complaint of acute chest pain, inconclusive initial evaluation (negative biomarkers, nondiagnostic electrocardiogram [ECG]), and no history of coronary artery disease (CAD). Patients underwent contrast-enhanced 64-multidetector-row cardiac CT and received standard clinical care (serial ECG, cardiac biomarkers, and subsequent diagnostic testing, such as exercise treadmill testing, nuclear stress perfusion imaging, and/or invasive coronary angiography), as deemed clinically appropriate. The clinical providers were blinded to CT results. The chest pain score was calculated and the results were dichotomized to ?10 (high-risk) and <10 (low-risk). Three risk scores were calculated, Goldman, Sanchis, and Thrombolysis in Myocardial Infarction (TIMI), and each patient was assigned to a low-, intermediate-, or high-risk category. Because of the low number of subjects in the high-risk group, the intermediate- and high-risk groups were combined into one. CT images were evaluated for the presence of plaque in 17 coronary segments. Plaque burden was stratified into none, intermediate, and high (zero, one to four, and more than four segments with plaque). An outcome panel of two physicians (blinded to CT findings) established the primary outcome of ACS (defined as either an acute myocardial infarction or unstable angina) during the index hospitalization (from the presentation to the ED to the discharge from the hospital). Logistic regression modeling was performed to examine the association of risk scores and coronary plaque burden to the outcome of ACS. Unadjusted models were individually fitted for the coronary plaque burden and for Goldman, Sanchis, TIMI, and chest pain scores. In adjusted analyses, the authors tested whether the association between risk scores and ACS persisted after controlling for the coronary plaque burden. The prognostic discriminatory capacity of the risk scores and plaque burden for ACS was assessed using c-statistics. The differences in area under the receiver-operating characteristic curve (AUC) and c-statistics were tested by performing the -2 log likelihood ratio test of nested models. A p value <0.05 was considered statistically significant.Among 368 subjects, 31 (8%) subjects were diagnosed with ACS. Goldman (AUC = 0.61), Sanchis (AUC = 0.71), and TIMI (AUC = 0.63) had modest discriminatory capacity for the diagnosis of ACS. Plaque burden was the strongest predictor of ACS (AUC = 0.86; p < 0.05 for all comparisons with individual risk scores). The combination of plaque burden and risk scores improved prediction of ACS (plaque + Goldman AUC = 0.88, plaque + Sanchis AUC = 0.90, plaque + TIMI AUC = 0.88; p < 0.01 for all comparisons with coronary plaque burden alone).Risk scores (Goldman, Sanchis, TIMI) have modest discriminatory capacity and coronary plaque burden has good discriminatory capacity for the diagnosis of ACS in patients with acute chest pain. The combined information of risk scores and plaque burden significantly improves the discriminatory capacity for the diagnosis of ACS.
View details for DOI 10.1111/j.1553-2712.2012.01417.x
View details for Web of Science ID 000307772300006
View details for PubMedID 22849339
A Computed Tomography-Based Coronary Lesion Score to Predict Acute Coronary Syndrome Among Patients With Acute Chest Pain and Significant Coronary Stenosis on Coronary Computed Tomographic Angiogram AMERICAN JOURNAL OF CARDIOLOGY 2012; 110 (2): 183-189
We tested the hypothesis that morphologic lesion assessment helps detect acute coronary syndrome (ACS) during index hospitalization in patients with acute chest pain and significant stenosis on coronary computed tomographic angiogram (CTA). Patients who presented to an emergency department with chest pain but no objective signs of myocardial ischemia (nondiagnostic electrocardiogram and negative initial biomarkers) underwent CT angiography. CTA was analyzed for degree and length of stenosis, plaque area and volume, remodeling index, CT attenuation of plaque, and spotty calcium in all patients with significant stenosis (>50% in diameter) on CTA. ACS during index hospitalization was determined by a panel of 2 physicians blinded to results of CT angiography. For lesion characteristics associated with ACS, we determined cutpoints optimized for diagnostic accuracy and created lesion scores. For each score, we determined the odds ratio (OR) and discriminatory capacity for the prediction of ACS. Of the overall population of 368 patients, 34 had significant stenosis and 21 of those had ACS. Scores A (remodeling index plus spotty calcium: OR 3.5, 95% confidence interval [CI] 1.2 to 10.1, area under curve [AUC] 0.734), B (remodeling index plus spotty calcium plus stenosis length: OR 4.6, 95% CI 1.6 to 13.7, AUC 0.824), and C (remodeling index plus spotty calcium plus stenosis length plus plaque volume <90 HU: OR 3.4, 95% CI 1.5 to 7.9, AUC 0.833) were significantly associated with ACS. In conclusion, in patients presenting with acute chest pain and stenosis on coronary CTA, a CT-based score incorporating morphologic characteristics of coronary lesions had a good discriminatory value for detection of ACS during index hospitalization.
View details for DOI 10.1016/j.amjcard.2012.02.066
View details for Web of Science ID 000307029500004
View details for PubMedID 22481015
Comparison of Exercise Treadmill Testing With Cardiac Computed Tomography Angiography Among Patients Presenting to the Emergency Room With Chest Pain The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) Study CIRCULATION-CARDIOVASCULAR IMAGING 2012; 5 (2): 233-242
The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA.The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis >50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 years old or women <50 years old or individuals who achieved at least 13 metabolic equivalents on ETT.Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.
View details for DOI 10.1161/CIRCIMAGING.111.969568
View details for Web of Science ID 000302122700012
View details for PubMedID 22308274
Coronary CTA assessment of coronary anomalies JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY 2012; 6 (1): 48-59
Coronary anomalies occur in <1% of the general population and can range from a benign incidental finding to the cause of sudden cardiac death. The coronary anomalies are classified here according to the traditional grouping into those of origin and course, intrinsic arterial anatomy, and termination. Classic coronary anomalies of origin and course include those in which a coronary artery originates from the contralateral aortic sinus or the pulmonary artery with anomalous course. Single coronary artery anomalies, in which single coronary artery branches to supply the entire coronary tree, are also included in this category. Anomalies of intrinsic arterial anatomy are a broad class that includes myocardial bridges, coronary ectasia and aneurysms, subendocardial coursing arteries, and coronary artery duplication. Coronary anomalies of termination are those in which a coronary artery terminates in a fistulous connection to a great vessel or cardiac chamber. In the case of those anomalies associated with a risk of sudden cardiac death, the relevant imaging features on CT angiography (CTA) associated with poorer prognosis are reviewed. Recent guidelines and appropriateness criteria favor the use of coronary CTA for the evaluation of coronary anomalies. Although invasive angiography has historically been used to diagnose coronary anomalies, multidetector CT imaging techniques have now become an accurate noninvasive alternative. Cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies.
View details for DOI 10.1016/j.jcct.2011.06.009
View details for Web of Science ID 000310933800008
View details for PubMedID 22264632
Reference Values for Normal Pulmonary Artery Dimensions by Noncontrast Cardiac Computed Tomography The Framingham Heart Study CIRCULATION-CARDIOVASCULAR IMAGING 2012; 5 (1): 147-154
Main pulmonary artery diameter (mPA) and ratio of mPA to ascending aorta diameter (ratio PA) derived from chest CT are commonly reported in clinical practice. We determined the age- and sex-specific distribution and normal reference values for mPA and ratio PA by CT in an asymptomatic community-based population.In 3171 men and women (mean age, 5110 years; 51% men) from the Framingham Heart Study, a noncontrast, ECG-gated, 8-slice cardiac multidetector CT was performed. We measured the mPA and transverse axial diameter of the ascending aorta at the level of the bifurcation of the right pulmonary artery and calculated the ratio PA. We defined the healthy referent cohort (n=706) as those without obesity, hypertension, current and past smokers, chronic obstructive pulmonary disease, history of pulmonary embolism, diabetics, cardiovascular disease, and heart valve surgery. The mean mPA diameter in the overall cohort was 25.12.8 mm and mean ratio PA was 0.770.09. The sex-specific 90th percentile cutoff value for mPA diameter was 28.9 mm in men and 26.9 mm in women and was associated with increase risk for self-reported dyspnea (adjusted odds ratio, 1.31; P=0.02). The 90th percentile cutoff value for ratio PA of the healthy referent group was 0.91, similar between sexes but decreased with increasing age (range, 0.82-0.94), though not associated with dyspnea.For simplicity, we established 29 mm in men and 27 mm in women as sex-specific normative reference values for mPA and 0.9 for ratio PA.
View details for DOI 10.1161/CIRCIMAGING.111.968610
View details for Web of Science ID 000300417100021
View details for PubMedID 22178898
Incremental value of myocardial perfusion over regional left ventricular function and coronary stenosis by cardiac CT for the detection of acute coronary syndromes in high-risk patients: A subgroup analysis of the ROMICAT trial JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY 2011; 5 (6): 382-391
To determine the incremental benefit of assessing myocardial perfusion defects (MPD) for acute coronary syndromes (ACS) over coronary and functional assessment by rest cardiac computed tomography (CT) in patients with acute chest pain.Assessment of myocardial perfusion is feasible with cardiac CT; however, the diagnostic value of this assessment in patients at risk for ACS has not been demonstrated.The study included patients who presented to the emergency department with acute chest pain, nonischemic initial electrocardiogram (ECG), and negative cardiac biomarkers but had clinical suspicion for ACS and underwent invasive coronary angiography (ICA). Results were blinded to caregivers and patients. CT data sets were independently assessed for the presence of coronary plaque and stenosis, regional left ventricular function, and myocardial perfusion deficits by 2 blinded observers. Coronary angiography was assessed for the presence of stenosis, TIMI myocardial perfusion grade, and corrected TIMI frame count. The endpoint was ACS during index hospitalization.We analyzed data from 35 subjects (69% male, mean age 58 9 years) of whom 22 (63%) had ACS. The sensitivity and specificity of MPD for ACS were 86% (95% CI: 64%-96%) and 62% (95% CI: 32%-85%), respectively. Combined, MPD and RWMA assessment resulted in specificity and sensitivity of 86% (95% CI: 64%-96%) and 85% (95% CI: 54%-97%), respectively. Adding MPD and RWMA to the assessment for significant stenosis (>50%) resulted in a higher sensitivity of 91% (69-98%) and specificity of 85% (54-97%) and a significantly increased overall diagnostic accuracy when compared with assessment for stenosis (AUC: 0.88 vs 0.79; respectively, P = 0.02). Diagnostic accuracy of CT was not associated with impaired CTFC >40 or myocardial TIMI perfusion grade < 3.Assessment of myocardial perfusion and regional wall motion abnormalities may enhance the ability of CT to detect ACS in patients with acute chest pain.
View details for DOI 10.1016/j.jcct.2011.10.004
View details for Web of Science ID 000310933700005
View details for PubMedID 22146497
A comparison of reconstruction and viewing parameters on image quality and accuracy of stress myocardial CT perfusion JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY 2011; 5 (6): 459-466
Myocardial stress computed tomography perfusion (CTP) has similar diagnostic accuracy for detecting perfusion defects (PDs) versus single-photon emission computed tomography (SPECT). However, the optimal diagnostic viewing and image processing parameters for CTP are unknown.We sought to compare the diagnostic accuracy of different image processing techniques, cardiac phases, slice thicknesses, and viewing parameters for detection of PDs.A stress and rest dual-source CTP protocol was performed with adenosine. Twelve subjects with severe stenosis proven by quantitative coronary angiography (QCA), with corresponding territorial defects at SPECT, were selected as well as 7 controls (subjects with similar clinical suspicion but negative QCA and SPECT). Short-axis stress images were processed with 3 techniques: minimum intensity projection (MinIP), maximum intensity projection, and average intensity multiplanar reconstruction (MPR), 3 thicknesses (1, 3, 8 mm), and 2 phases (systolic, mid-diastolic). The resulting images (n = 1026) were randomized and interpreted by independent readers.Diastolic reconstructions (8-mm MPR) showed the highest sensitivity (81%) to detect true PDs. The highest accuracy was achieved with the 8-mm (61%) and 1-mm (61%) MPR diastolic images. The most sensitive and accurate systolic reconstructions were 3-mm MinIP images. These findings related to viewing in relatively narrow window width and window level settings.Viewing parameters for optimal accuracy in detection of perfusion defects on CTP differ for systolic and diastolic images.
View details for DOI 10.1016/j.jcct.2011.10.011
View details for Web of Science ID 000310933700013
View details for PubMedID 22146505
Imaging of coronary inflammation with FDG-PET: feasibility and clinical hurdles. Current cardiology reports 2011; 13 (2): 138-144
Conventional algorithms and noninvasive imaging tests for the identification of stable, hemodynamically significant coronary artery disease offer little insight into the detection of potentially vulnerable and inflamed coronary plaques, those most likely to rupture and cause acute coronary syndromes. Positron emission tomography (PET) with fluorodeoxyglucose (FDG) serves as a potential novel modality for the identification of plaque inflammation, as initial studies in animal and human studies have demonstrated that FDG uptake correlates with macrophage accumulation and inflammation. Therapy with anti-inflammatory agents has also been demonstrated in the arterial vasculature to reduce plaque FDG uptake. Although imaging of coronary inflammation with FDG-PET holds tremendous promise, several hurdles remain to be surmounted prior to widespread clinical application.
View details for DOI 10.1007/s11886-011-0168-3
View details for PubMedID 21274660
Use of 100 kV versus 120 kV in cardiac dual source computed tomography: effect on radiation dose and image quality INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2011; 27 (4): 579-586
To evaluate the effective radiation dose and image quality resulting from use of 100 vs. 120 kV among patients referred for cardiac dual source CT exam (DSCT). Prospective data was collected on 294 consecutive patients referred for DSCT. For each scan, a physician specializing in cardiac CT chose all parameters including tube current and voltage, axial versus helical acquisition, and use of tube current modulation. Lower tube voltage was selected for thinner patients or when lower radiation was desired for younger patients, particularly females. For each study, image quality (IQ) was rated on a subjective IQ score and contrast (CNR) and signal-to-noise (SNR) ratios were calculated. Tube voltage of 100 kV was used for 77 (26%) exams while 120 kV was used for 217 (74%) exams. Use of 100 kV was more common in thinner patients (weight 166 lbs vs. 199 lbs, P < .001). The effective radiation dose for the 100 and 120 kV scans was 8.5 and 15.4 mSv respectively. Among scans utilizing 100 and 120 kV, there was no difference in exam indication, use of beta blockers, heart rate, scan length and use of radiation saving techniques such as prospective ECG triggering and tube current modulation. The IQ score was significantly higher for 100 kV scans. While 100 kV scans were found to have higher image noise then those utilizing 120 kV, the contrast-to-noise and signal-to-noise were significantly higher (SNR: 9.4 vs. 8.3, P = .02; CNR: 6.9 vs. 6.0, P = .02). In selected non-obese patients, use of low kV results in a substantial reduction of radiation dose and may result in improved image quality. These results suggest that low kV should be used more frequently in non-obese patients.
View details for DOI 10.1007/s10554-010-9683-3
View details for Web of Science ID 000290967900012
View details for PubMedID 20721630
Usefulness of Comprehensive Cardiothoracic Computed Tomography in the Evaluation of Acute Undifferentiated Chest Discomfort in the Emergency Department (CAPTURE) AMERICAN JOURNAL OF CARDIOLOGY 2011; 107 (5): 643-650
Newer cardiac computed tomographic (CT) technology has permitted comprehensive cardiothoracic evaluations for coronary artery disease, pulmonary embolism, and aortic dissection within a single breath hold, independent of the heart rate. We conducted a randomized diagnostic trial to compare the efficiency of a comprehensive cardiothoracic CT examination in the evaluation of patients presenting to the emergency department with undifferentiated acute chest discomfort or dyspnea. We randomized the emergency department patients clinically scheduled to undergo a dedicated CT protocol to assess coronary artery disease, pulmonary embolism, or aortic dissection to either the planned dedicated CT protocol or a comprehensive cardiothoracic CT protocol. All CT examinations were performed using a 64-slice dual source CT scanner. The CT results were immediately communicated to the emergency department providers, who directed further management at their discretion. The subjects were then followed for the remainder of their hospitalization and for 30 days after hospitalization. Overall, 59 patients (mean age 51.2 11.4 years, 72.9% men) were randomized to either dedicated (n = 30) or comprehensive (n = 29) CT scanning. No significant difference was found in the median length of stay (7.6 vs 8.2 hours, p = 0.79), rate of hospital discharge without additional imaging (70% vs 69%, p = 0.99), median interval to exclusion of an acute event (5.2 vs 6.5 hours, p = 0.64), costs of care (p = 0.16), or the number of revisits (p = 0.13) between the dedicated and comprehensive arms, respectively. In addition, radiation exposure (11.3 mSv vs 12.8 mSv, p = 0.16) and the frequency of incidental findings requiring follow-up (24.1% vs 33.3%, p = 0.57) were similar between the 2 arms. Comprehensive cardiothoracic CT scanning was feasible, with a similar diagnostic yield to dedicated protocols. However, it did not reduce the length of stay, rate of subsequent testing, or costs. In conclusion, although this "triple rule out" protocol might be helpful in the evaluation of select patients, these findings suggest that it should not be used routinely with the expectation that it will improve efficiency or reduce resource use.
View details for DOI 10.1016/j.amjcard.2010.10.039
View details for Web of Science ID 000287837200001
View details for PubMedID 21247533
Left atrial volume and index by multi-detector computed tomography: Comprehensive analysis from predictors of enlargement to predictive value for acute coronary syndrome (ROMICAT study) INTERNATIONAL JOURNAL OF CARDIOLOGY 2011; 146 (2): 171-176
We aimed to identify the predictors of left atrial (LA) enlargement by multi-detector computed tomography (CT) and determine its association and predictive value for acute coronary syndrome (ACS).LA enlargement is associated with myocardial ischemia and coronary artery disease (CAD) and is a strong predictor for cardiovascular events. These studies were performed primarily with echocardiography. With the rise of cardiac CT, LA volume can be readily measured.In 377 emergency department patients with chest pain, we performed 64-slice CT for coronary artery assessment. We derived LA volumes (LAV(max), LAV(min)) and indices (LAVI(max), LAVI(min)) using a threshold-based volumetric method.Subjects, with cardiac risk factors or CAD by CT, had larger LA (?LAV(max) 9.1 ml, p=0.004; ?LAV(min) 8.1 ml, p=0.001; ?LAVI(max) 3.3 ml/m(2), p=0.03; ?LAVI(min) 3.4 ml/m(2), p=0.006) than controls. Predictors of LA enlargement were related to risk factors for diastolic dysfunction. ACS risk was greater in patients with top quartile LAV(max) (odds ratio [OR] 3.4, p=0.02) and LAV(min) (OR 4.7, p=0.01) than lowest quartile, but not when indexed. Similarly, the predictive values of LA volumes were incrementally better when added to CT finding of indeterminate stenosis (LAV(max): C statistic 0.62 to 0.70, p=0.046; LAV(min): C statistic 0.65 to 0.73, p=0.008), but not when indexed.Risk factors related to diastolic dysfunction are independent predictors of LA enlargement. LA enlargement by volumes are associated with a 3-5 fold increase risk for ACS and have incremental value for predicting ACS when added to the CT finding of indeterminate stenosis.
View details for DOI 10.1016/j.ijcard.2009.06.029
View details for Web of Science ID 000286184400014
View details for PubMedID 19615769
Comparison of postprocessing techniques for the detection of perfusion defects by cardiac computed tomography in patients presenting with acute ST-segment elevation myocardial infarction JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY 2010; 4 (4): 258-266
Incremental Diagnostic Value of Regional Left Ventricular Function Over Coronary Assessment by Cardiac Computed Tomography for the Detection of Acute Coronary Syndrome in Patients With Acute Chest Pain From the ROMICAT Trial CIRCULATION-CARDIOVASCULAR IMAGING 2010; 3 (4): 375-383
The incremental value of regional left ventricular function (LVF) over coronary assessment to detect acute coronary syndrome (ACS) is uncertain.We analyzed 356 patients (mean age, 53+/-12 years; 62% men) with acute chest pain and inconclusive initial emergency department evaluation. Patients underwent 64-slice contrast-enhanced cardiac computed tomography before hospital admission. Caregivers and patients remained blinded to the results. Regional LVF and presence of coronary atherosclerotic plaque and significant stenosis (>50%) were separately assessed by 2 independent readers. Incremental value of regional LVF to predict ACS was determined in the entire cohort and in subgroups of patients with nonobstructive coronary artery disease, inconclusive assessment for stenosis (defined as inability to exclude significant stenosis due to calcium or motion), and significant stenosis. During their index hospitalization, 31 patients were ultimately diagnosed with ACS (8 myocardial infarction, 22 unstable angina), of which 74% (23 patients) had regional LV dysfunction. Adding regional LVF resulted in a 10% increase in sensitivity to detect ACS by cardiac computed tomography (87%; 95% confidence interval, 70% to 96%) and significantly improved the overall accuracy (c-statistic: 0.88 versus 0.94 and 0.79 versus 0.88, for extent of plaque and presence of stenosis, respectively; both P<0.03). The diagnostic accuracy of regional LVF for detection of ACS has 89% sensitivity and 86% specificity in patients with significant stenosis (n=33) and 60% sensitivity and 86% specificity in patients with inconclusive coronary computed tomographic angiography (n=33).Regional LVF assessment at rest improves diagnostic accuracy for ACS in patients with acute chest pain, especially in those with coronary artery disease and thus may be helpful to guide further management in patients at intermediate risk for ACS.
View details for DOI 10.1161/CIRCIMAGING.109.892638
View details for Web of Science ID 000280149200005
View details for PubMedID 20484542
Comparison of postprocessing techniques for the detection of perfusion defects by cardiac computed tomography in patients presenting with acute ST-segment elevation myocardial infarction. Journal of cardiovascular computed tomography 2010; 4 (4): 258-266
Despite rapid advances in cardiac computed tomography (CT), a strategy for optimal visualization of perfusion abnormalities on CT has yet to be validated.We evaluated the performance of several postprocessing techniques of source data sets to detect and characterize perfusion defects in acute myocardial infarctions with cardiac CT.Twenty-one subjects (18 men; 60 +/- 13 years) that were successfully treated with percutaneous coronary intervention for ST-segment myocardial infarction underwent 64-slice cardiac CT and 1.5 Tesla cardiac magnetic resonance imaging (MRI) scans after revascularization. Delayed enhancement MR images were analyzed to identify the location of infarcted myocardium. Contiguous short-axis images of the left ventricular myocardium were created from the CT source images with 0.75-mm multiplanar reconstruction (MPR), 5-mm MPR, 5-mm maximal intensity projection (MIP), and 5-mm minimum intensity projection (MinIP) techniques. Segments already confirmed to contain infarction by MRI were then evaluated qualitatively and quantitatively with CT.Overall, 143 myocardial segments were analyzed. On qualitative analysis, the MinIP and thick MPR techniques had greater visibility and definition than the thin MPR and MIP techniques (P < 0.001). On quantitative analysis, the absolute difference in Hounsfield unit attenuation between normal and infarcted segments was significantly greater for the MinIP (65.4 Hounsfield unit [HU]) and thin MPR (61.2 HU) techniques. However, the relative difference in Hounsfield unit attenuation was significantly greatest for the MinIP technique alone (95%; P < 0.001). Contrast to noise was greatest for the MinIP (4.2) and thick MPR (4.1) techniques (P < 0.001).The results of our current investigation found that MinIP and thick MPR detected infarcted myocardium with greater visibility and definition than MIP and thin MPR.
View details for DOI 10.1016/j.jcct.2010.04.003
View details for PubMedID 20579617
Feasibility of FDG Imaging of the Coronary Arteries Comparison Between Acute Coronary Syndrome and Stable Angina JACC-CARDIOVASCULAR IMAGING 2010; 3 (4): 388-397
This study tested the hypothesis that fluorodeoxyglucose (FDG) uptake within the ascending aorta and left main coronary artery (LM), measured using positron emission tomography (PET), is greater in patients with recent acute coronary syndrome (ACS) than in patients with stable angina.Inflammation is known to play an important role in atherosclerosis. Positron emission tomography imaging with (18)F-FDG provides a measure of plaque inflammation.Twenty-five patients (mean age 57.9 +/- 9.8 years, 72% male, 10 ACS, and 15 stable angina) underwent cardiac computed tomographic angiography and PET imaging with (18)F-FDG after invasive angiography. Images were coregistered, and FDG uptake was measured at locations of interest for calculation of target-to-background ratios (TBR). Additionally, FDG uptake was measured at the site of the lesion deemed clinically responsible for the presenting syndrome (culprit) by virtue of locating the stent deployed to treat the syndrome.The FDG uptake was higher in the ACS versus the stable angina groups in the ascending aorta (median [interquartile ranges] TBR 3.30 [2.69 to 4.12] vs. 2.43 [2.00 to 2.86], p = 0.02), as well as the LM (2.48 [2.30 to 2.93] vs. 2.00 [1.71 to 2.44], p = 0.03, respectively). The TBR was greater for culprit lesions associated with ACS than for lesions stented for stable coronary syndromes (2.61 vs. 1.74, p = 0.02). Furthermore, the TBR in the stented lesions (in ACS and stable angina groups) correlated with C-reactive protein (r = 0.58, p = 0.04).This study shows that in patients with recent ACS, FDG accumulation is increased both within the culprit lesion as well as in the ascending aorta and LM. This observation suggests inflammatory activity within atherosclerotic plaques in acute coronary syndromes and supports intensification of efforts to refine PET methods for molecular imaging of coronary plaques.
View details for DOI 10.1016/j.jcmg.2010.01.004
View details for Web of Science ID 000281625900009
View details for PubMedID 20394901
Predictors of image quality of coronary computed tomography in the acute care setting of patients with chest pain EUROPEAN JOURNAL OF RADIOLOGY 2010; 74 (1): 182-188
We aimed to determine predictors of image quality in consecutive patients who underwent coronary computed tomography (CT) for the evaluation of acute chest pain.We prospectively enrolled patients who presented with chest pain to the emergency department. All subjects underwent contrast-enhanced 64-slice coronary multi-detector CT. Two experienced readers determined overall image quality on a per-patient basis and the prevalence and characteristics of non-evaluable coronary segments on a per-segment basis.Among 378 subjects (143 women, age: 52.9+/-11.8 years), 345 (91%) had acceptable overall image quality, while 33 (9%) had poor image quality or were unreadable. In adjusted analysis, patients with diabetes, hypertension and a higher heart rate during the scan were more likely to have exams graded as poor or unreadable (odds ratio [OR]: 2.94, p=0.02; OR: 2.62, p=0.03; OR: 1.43, p=0.02; respectively). Of 6253 coronary segments, 257 (4%) were non-evaluable, most due to severe calcification in combination with motion (35%). The presence of non-evaluable coronary segments was associated with age (OR: 1.08 annually, 95%-confidence interval [CI]: 1.05-1.12, p<0.001), baseline heart rate (OR: 1.35 per 10 beats/min, 95%-CI: 1.11-1.67, p=0.003), diabetes, hypertension, and history of coronary artery disease (OR: 4.43, 95%-CI: 1.93-10.17, p<0.001; OR: 2.27, 95-CI: 1.01-4.73, p=0.03; OR: 5.12, 95%-CI: 2.0-13.06, p<0.001; respectively).Coronary CT permits acceptable image quality in more than 90% of patients with chest pain. Patients with multiple risk factors are more likely to have impaired image quality or non-evaluable coronary segments. These patients may require careful patient preparation and optimization of CT scanning protocols.
View details for DOI 10.1016/j.ejrad.2009.03.001
View details for Web of Science ID 000277565200029
View details for PubMedID 19346094
Incremental Value of Adenosine-induced Stress Myocardial Perfusion Imaging with Dual-Source CT at Cardiac CT Angiography RADIOLOGY 2010; 254 (2): 410-419
First, to assess the feasibility of a protocol involving stress-induced perfusion evaluated at computed tomography (CT) combined with cardiac CT angiography in a single examination and second, to assess the incremental value of perfusion imaging over cardiac CT angiography in a dual-source technique for the detection of obstructive coronary artery disease (CAD) in a high-risk population.Institutional review board approval and informed patient consent were obtained before patient enrollment in the study. The study was HIPAA compliant. Thirty-five patients at high risk for CAD were prospectively enrolled for evaluation of the feasibility of CT perfusion imaging. All patients underwent retrospectively electrocardiographically gated (helical) adenosine stress CT perfusion imaging followed by prospectively electrocardiographically gated (axial) rest myocardial CT perfusion imaging. Analysis was performed in three steps: (a)Coronary arterial stenoses were scored for severity and reader confidence at cardiac CT angiography, (b)myocardial perfusion defects were identified and scored for severity and reversibility at CT perfusion imaging, and (c)coronary stenosis severity was reclassified according to perfusion findings at combined cardiac CT angiography and CT perfusion imaging. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of cardiac CT angiography before and after CT perfusion analysis were calculated.With use of a reference standard of greater than 50% stenosis at invasive angiography, all parameters of diagnostic accuracy increased after CT perfusion analysis: Sensitivity increased from 83% to 91%; specificity, from 71% to 91%; PPV, from 66% to 86%; and NPV, from 87% to 93%. The area under the receiver operating characteristic curve increased significantly, from 0.77 to 0.90 (P < .005).A combination protocol involving adenosine perfusion CT imaging and cardiac CT angiography in a dual-source technique is feasible, and CT perfusion adds incremental value to cardiac CT angiography in the detection of significant CAD.
View details for DOI 10.1148/radiol.09091014
View details for Web of Science ID 000273824600012
View details for PubMedID 20093513
Direct comparison of rest and adenosine stress myocardial perfusion CT with rest and stress SPECT JOURNAL OF NUCLEAR CARDIOLOGY 2010; 17 (1): 27-37
We have recently described a technique for assessing myocardial perfusion using adenosine-mediated stress imaging (CTP) with dual source computed tomography. SPECT myocardial perfusion imaging (SPECT-MPI) is a widely utilized and extensively validated method for assessing myocardial perfusion. The aim of this study was to determine the level of agreement between CTP and SPECT-MPI at rest and under stress on a per-segment, per-vessel, and per-patient basis.Forty-seven consecutive patients underwent CTP and SPECT-MPI. Perfusion images were interpreted using the 17 segment AHA model and were scored on a 0 (normal) to 3 (abnormal) scale. Summed rest and stress scores were calculated for each vascular territory and patient by adding corresponding segmental scores.On a per-segment basis (n = 799), CTP and SPECT-MPI demonstrated excellent correlation: Goodman-Kruskall gamma = .59 (P < .0001) for stress and .75 (P < .0001) for rest. On a per-vessel basis (n = 141), CTP and SPECT-MPI summed scores demonstrated good correlation: Pearson r = .56 (P < .0001) for stress and .66 (P < .0001) for rest. On a per-patient basis (n = 47), CTP and SPECT-MPI demonstrated good correlation: Pearson r = .60 (P < .0001) for stress and .76 (P < .0001) for rest.CTP compares favorably with SPECT-MPI for detection, extent, and severity of myocardial perfusion defects at rest and stress.
View details for DOI 10.1007/s12350-009-9156-z
View details for Web of Science ID 000273853600007
View details for PubMedID 19936863
Relation of left ventricular mass and concentric remodeling to extent of coronary artery disease by computed tomography in patients without left ventricular hypertrophy: ROMICAT study JOURNAL OF HYPERTENSION 2009; 27 (12): 2472-2482
Cardiac computed tomography allows for simultaneous assessment of left ventricular mass (LVM) and coronary artery disease (CAD). We aimed to determine whether LVM, LVM index (LVMi), and the left ventricular geometric pattern of concentric remodeling are associated with the extent of CAD in patients without left ventricular hypertrophy.In 348 patients from the Rule Out Myocardial Infarction Using Computer Assisted Tomography trial, 64-slice computed tomography was performed and LVM measured at end-diastole. We used three LVM indexation criteria to obtain three cohorts: LVM indexed to body surface area by echocardiography (n = 337) and computed tomography criteria (n = 325), and by height (n = 326). The cohorts were subdivided into concentric remodeling and normal geometry. Extent of coronary plaque was classified based on a 17-segment model, treated as a continuous variable, and stratified into three groups: zero segment, one to four segments, and more than four segments.Patients with more than four segments of coronary plaque had higher LVM (Delta12.8-15.1 g) and LVMi (Delta4.0-5.5 g/m and Delta2.2 g/m) than those without CAD (all P < or = 0.03). After multivariable adjustment, LVM and LVMi remained independent predictors of extent of coronary plaque, with 0.27-0.29 segments more plaque per 20 g increase of LVM (all P = 0.02), 0.32-0.34 segments more plaque per 10 g/m increase of LVMi (both P = 0.02), and 0.80 segments more plaque per 10 g/m increase of LVMi (P = 0.008). Concentric remodeling patients had 1.1-1.3 segments more plaque than those with normal geometry (all P < or = 0.05). Patients with more than four segments of plaque had two-fold increase in odds (all P < or = 0.05) of having concentric remodeling as compared with those without CAD.Increased LVM, LVMi, and concentric remodeling are associated with a greater degree of coronary plaque burden in patients without left ventricular hypertrophy. These findings could provide an indication to intensify medical therapy in patients with subclinical CAD and hypertension.
View details for DOI 10.1097/HJH.0b013e328331054a
View details for Web of Science ID 000272420800024
View details for PubMedID 19696685
Usefulness of Age and Gender in the Early Triage of Patients With Acute Chest Pain Having Cardiac Computed Tomographic Angiography AMERICAN JOURNAL OF CARDIOLOGY 2009; 104 (9): 1165-1170
To identify the age- and gender-specific subpopulations of patients with acute chest pain in whom coronary computed tomographic angiography (CTA) will yield the greatest diagnostic benefit. Subjects with acute chest pain and an inconclusive initial evaluation (nondiagnostic electrocardiograhic findings, negative cardiac biomarkers) underwent contrast-enhanced 64-slice coronary CTA as a part of an observational cohort study. Independent investigators determined the presence of significant coronary stenosis (>50% luminal narrowing) and the occurrence of acute coronary syndrome (ACS) during the index hospitalization. We determined the diagnostic accuracy and effect on pretest probability of ACS using Bayes' theorem by age and gender. Of 368 patients (age 52.7 +/- 12 years, 61% men), 8% had ACS. The presence of significant coronary stenosis on CTA and the occurrence of ACS increased with age for both men and women (p <0.001). Cardiac CTA was highly sensitive and specific in women <65 years of age (sensitivity 100% and specificity >87%) and men <55 years of age (sensitivity 100% for men <45 years and 80% for men 45 to 54 years old; specificity >88.2%). Moreover, in these patients, coronary CTA led to restratification from low to high risk (for positive findings on CTA) or from low to very low risk (for negative findings on CTA). In contrast, a negative result on CTA did not result in restratification to a low-risk category in women >65 years and men >55 years old. In conclusion, the present analysis provides initial evidence that men <55 years and women <65 years might benefit more from cardiac CTA than older patients. Thus, age and gender might serve as simple criteria to appropriately select patients who would derive the greatest diagnostic benefit from coronary CTA in the setting of acute chest pain.
View details for DOI 10.1016/j.amjcard.2009.06.029
View details for Web of Science ID 000271487100001
View details for PubMedID 19840556
Association of aortic valve calcification to the presence, extent, and composition of coronary artery plaque burden: From the Rule Out Myocardial Infarction using Computer Assisted Tomography (ROMICAT) trial AMERICAN HEART JOURNAL 2009; 158 (4): 562-568
Aortic valve calcification (AVC) is associated with cardiovascular risk factors and coronary artery calcification. We sought to determine whether AVC is associated with the presence and extent of overall plaque burden, as well as to plaque composition (calcified, mixed, and noncalcified).We examined 357 subjects (mean age 53 +/- 12 years, 61% male) who underwent contrast-enhanced electrocardiogram-gated 64-slice multidetector computed tomography from the ROMICAT trial for the assessment of presence and extent of coronary plaque burden according to the 17-coronary segment model and presence of AVC.Patients with AVC (n = 37, 10%) were more likely than those without AVC (n = 320, 90%) to have coexisting presence of any coronary plaque (89% vs 46%, P < .001) and had a greater extent of coronary plaque burden (6.4 vs 1.8 segments, P < .001). Those with AVC had >3-fold increase odds of having any plaque (adjusted odds ratio [OR] 3.6, P = .047) and an increase of 2.5 segments of plaque (P < .001) as compared to those without AVC. When stratified by plaque composition, AVC was associated most with calcified plaque (OR 5.2, P = .004), then mixed plaque (OR 3.2, P = .02), but not with noncalcified plaque (P = .96).Aortic valve calcification is associated with the presence and greater extent of coronary artery plaque burden and may be part of the later stages of the atherosclerosis process, as its relation is strongest with calcified plaque, less with mixed plaque, and nonsignificant with noncalcified plaque. If AVC is present, consideration for aggressive medical therapy may be warranted.
View details for DOI 10.1016/j.ahj.2009.07.027
View details for Web of Science ID 000270706100011
View details for PubMedID 19781415
Adenosine-Induced Stress Myocardial Perfusion Imaging Using Dual-Source Cardiac Computed Tomography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2009; 54 (12): 1072-1084
This study sought to determine the feasibility of performing a comprehensive cardiac computed tomographic (CT) examination incorporating stress and rest myocardial perfusion imaging together with coronary computed tomography angiography (CTA).Although cardiac CT can identify coronary stenosis, very little data exist on the ability to detect stress-induced myocardial perfusion defects in humans.Thirty-four patients who had a nuclear stress test and invasive angiography were included in the study. Dual-source computed tomography (DSCT) was performed as follows: 1) stress CT: contrast-enhanced scan during adenosine infusion; 2) rest CT: contrast-enhanced scan using prospective triggering; and 3) delayed scan: acquired 7 min after rest CT. Images for CTA, computed tomography perfusion (CTP), and single-photon emission computed tomography (SPECT) were each read by 2 independent blinded readers.The DSCT protocol was successfully completed for 33 of 34 subjects (average age 61.4 +/- 10.7 years; 82% male; body mass index 30.4 +/- 5 kg/m(2)) with an average radiation dose of 12.7 mSv. On a per-vessel basis, CTP alone had a sensitivity of 79% and a specificity of 80% for the detection of stenosis > or =50%, whereas SPECT myocardial perfusion imaging had a sensitivity of 67% and a specificity of 83%. For the detection of vessels with > or =50% stenosis with a corresponding SPECT perfusion abnormality, CTP had a sensitivity of 93% and a specificity of 74%. The CTA during adenosine infusion had a per-vessel sensitivity of 96%, specificity of 73%, and negative predictive value of 98% for the detection of stenosis > or =70%.Adenosine stress CT can identify stress-induced myocardial perfusion defects with diagnostic accuracy comparable to SPECT, with similar radiation dose and with the advantage of providing information on coronary stenosis.
View details for DOI 10.1016/j.jacc.2009.06.014
View details for Web of Science ID 000269624000004
View details for PubMedID 19744616
Association between diabetes and different components of coronary atherosclerotic plaque burden as measured by coronary multidetector computed tomography ATHEROSCLEROSIS 2009; 205 (2): 481-485
The aim of the study was to assess differences in the presence, extent, and composition of coronary atherosclerotic plaque burden as detected by coronary multidetector computed tomography (MDCT) between patients with and without diabetes mellitus.We compared coronary atherosclerotic plaques (any plaque, calcified [CAP], non-calcified [NCAP, and mixed plaque [MCAP]]) between 144 symptomatic diabetic and non-diabetic patients (36 diabetics, mean age: 54.4+/-12, 64% females) who underwent coronary 64-slice MDCT (Siemens Medical Solutions, Forchheim, Germany) for the evaluation of acute chest pain but proven absence of myocardial ischemia.Patients with diabetes had a higher prevalence of any plaque, CAP, MCAP, and NCAP (p=0.08, 0.07, 0.05, and 0.05, respectively) and a significantly higher extent of any plaque, CAP, MCAP, and NCAP (3.8+/-4.2 vs. 2.0+/-3.2, p=0.01; 3.3+/-4.0 vs. 1.7+/-3.0, p=0.03; 1.4+/-2.6 vs. 0.6+/-1.5, p=0.03; and 1.9+/-3.0 vs. 1.0+/-1.9, p=0.03, respectively) as compared to controls. In addition, patients with diabetes had a significant higher prevalence of significant coronary artery stenosis (42% vs. 14%, p=0.0004) and an approximately 3.5-fold higher risk of significant coronary stenosis independent of the presence of hypertension and BMI (OR: 3.46, 95% CI: 1.37-8.74, p=0.009).Patients with diabetes have an approximately 3.5-fold higher risk of coronary stenosis independent of other cardiovascular risk factors and an overall increased coronary atherosclerotic plaque burden.
View details for DOI 10.1016/j.atherosclerosis.2009.01.015
View details for Web of Science ID 000269289500025
View details for PubMedID 19230889
Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain The ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) Trial JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2009; 53 (18): 1642-1650
This study was designed to determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain.Triage of chest pain patients in the emergency department remains challenging.We used an observational cohort study in chest pain patients with normal initial troponin and nonischemic electrocardiogram. A 64-slice coronary CTA was performed before admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. End points were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events during 6-month follow-up.Among 368 patients (mean age 53 +/- 12 years, 61% men), 31 had ACS (8%). By coronary CTA, 50% of these patients were free of coronary artery disease (CAD), 31% had nonobstructive disease, and 19% had inconclusive or positive computed tomography for significant stenosis. Sensitivity and negative predictive value for ACS were 100% (n = 183 of 368; 95% confidence interval [CI]: 98% to 100%) and 100% (95% CI: 89% to 100%), respectively, with the absence of CAD and 77% (95% CI: 59% to 90%) and 98% (n = 300 of 368, 95% CI: 95% to 99%), respectively, with significant stenosis by coronary CTA. Specificity of presence of plaque and stenosis for ACS were 54% (95% CI: 49% to 60%) and 87% (95% CI: 83% to 90%), respectively. Only 1 ACS occurred in the absence of calcified plaque. Both the extent of coronary plaque and presence of stenosis predicted ACS independently and incrementally to Thrombolysis In Myocardial Infarction risk score (area under curve: 0.88, 0.82, vs. 0.63, respectively; all p < 0.0001).Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS were free of CAD by computed tomography and had no ACS. Given the large number of such patients, early coronary CTA may significantly improve patient management in the emergency department.
View details for DOI 10.1016/j.jacc.2009.01.052
View details for Web of Science ID 000265628500003
View details for PubMedID 19406338
Thrombolysis in Myocardial Infarction (TIMI) Risk Index predicts long-term mortality and heart failure in patients with ST-elevation myocardial infarction in the TIMI 2 clinical trial AMERICAN HEART JOURNAL 2009; 157 (4): 673-679
TIMI (Thrombolysis in Myocardial Infarction) Risk Index (TRI) is a simple bedside score that predicts 30-day mortality in patients with ST-elevation myocardial infarction (MI). We sought to evaluate whether TRI was predictive of long-term mortality and clinical events.In the TIMI 2 trial, 3,153 patients (mean age 57 +/- 10 years, 82% men) were randomized to invasive (n = 1,583) versus conservative (n = 1,570) strategy postfibrinolysis with median follow-up of 3 years. TIMI Risk Index was divided into 5 groups. The primary end point was all-cause mortality. Secondary analyses included recurrent MI, congestive heart failure (CHF), and combined end points.When compared with group 1, mortality in group 5 was more than 5-fold higher (hazard ratio [HR] 5.83, P < .0001) and was also increased in group 4 (HR 2.80, P < .0001) and group 3 (HR 1.96, P = .002) (c statistic 0.69). No difference was seen between groups 1 and 2 (P = .74). A similar increasing gradient effect was seen across TRI strata with group 5 having the highest risk for CHF (HR 4.13, P < .0001) and the highest risk for composite death/CHF (HR 4.35, P < .0001) over group 1. There was no difference in recurrent MI between the groups (P = .22). After controlling for other risk indicators, the relationship between TRI and mortality remained significant: group 5, HR 4.11, P < .0001; group 4, HR 2.14, P = .0009; group 3, HR 1.69, P = .02. When stratified by TRI groups, no differences in mortality or composite death/MI were found between treatment strategies.The simple TRI can predict increased long-term mortality, CHF, and composite death/CHF.
View details for DOI 10.1016/j.ahj.2008.12.010
View details for Web of Science ID 000265110100013
View details for PubMedID 19332194
Practical tips and tricks in cardiovascular computed tomography: diagnosis of myocardial infarction. Journal of cardiovascular computed tomography 2009; 3 (2): 104-111
In addition to accurately diagnosing coronary artery disease, cardiac CT (CCT) has the potential to provide information on myocardial function, perfusion, and viability. As ongoing research continues to support the utility of such noncoronary uses of CCT, this information is increasingly being integrated into clinical practice. An emerging important use of CCT is the ability to accurately identify areas of infarcted myocardium. From a clinical perspective, detecting and quantifying infarct size has important prognostic and therapeutic implications. This article provides a brief overview on the use of CT to diagnose myocardial infarction (MI) and provide practical "tips and tricks" that can aid in the CT-based detection of MI.
View details for DOI 10.1016/j.jcct.2008.10.014
View details for PubMedID 19332342
Presence and Extent of Coronary Artery Disease by Cardiac Computed Tomography and Risk for Acute Coronary Syndrome in Cocaine Users Among Patients With Chest Pain AMERICAN JOURNAL OF CARDIOLOGY 2009; 103 (5): 620-625
Cocaine users represent an emergency department (ED) population that has been shown to be at increased risk for acute coronary syndrome (ACS); however, there is controversy about whether this higher risk is mediated through advanced atherosclerosis. Thus, we aimed to determine whether history of cocaine use is associated with ACS and coronary artery disease. In this matched cohort study, we selected patients with a history of cocaine use and age- and gender-matched controls from a large cohort of consecutive patients who presented with acute chest pain to the ED. Coronary atherosclerotic plaque as detected by 64-slice coronary computed tomography was compared between the groups. Among 412 patients, 44 had a history of cocaine use (9%) and were matched to 132 controls (mean age 46 +/- 6 years, 86% men). History of cocaine use was associated with a sixfold higher risk for ACS (odds ratio 5.79, 95% confidence interval 1.24 to 27.02, p = 0.02), but was not associated with a higher prevalence of any plaque, calcified plaque, or noncalcified plaque (all p>0.58) or the presence of significant stenosis (p = 0.09). History of cocaine use was also not associated with the extent of any, calcified, or noncalcified plaque (all p>0.12). These associations persisted after adjustment for other cardiovascular risk factors. In conclusion, in patients presenting to the emergency department with acute chest pain, history of cocaine use is associated with an increase in risk for ACS; however, this was not attributable to a higher presence or extent of coronary atherosclerotic plaque.
View details for DOI 10.1016/j.amjcard.2008.11.011
View details for Web of Science ID 000263986500009
View details for PubMedID 19231323
Images in cardiovascular medicine. The traveling amplatzer: rare complication of percutaneous atrial septal occluder device embolism. Circulation 2008; 118 (5): e93-6
Incidental discovery of a rare single coronary artery anomaly by cardiac multidetector computed tomography. Journal of cardiovascular computed tomography 2008; 2 (1): 59-60
Postpartum dissection of the left main coronary artery CLINICAL CARDIOLOGY 2006; 29 (4): 175-178
Peripartum coronary artery dissection is rare, but it is an increasingly recognized risk to women of childbearing age. Literature reviews reveal that about 80% of the population with spontaneous coronary artery dissections (SCAD) are female, and approximately 25-33% of cases occurred while the woman was pregnant or in the peripartum phase. Most cases have presented within 2 weeks of delivery. The left anterior descending is the most commonly affected vessel. The etiology is poorly understood, but many reports suggest that SCAD occurs as a result of protease release secondary to an eosinophilic vasculitis resulting in vessel lysis. Many investigators have examined the correlation between peripartum SCAD and estrogen levels; however, case studies have shown conflicting results regarding estrogen levels as the putative causative factor. Optimal treatment remains controversial. Presently, stenting appears to be best employed in the patients who have single-vessel dissection not involving the left main coronary artery (LMCA). Surgical revascularization via coronary artery bypass graft remains the optimal therapy in patients whose dissection involves the LMCA, in patients with concurrent multivessel dissection, and in patients with disease refractory to medical management. It is important to consider coronary artery dissection in the differential of any young woman who presents with signs or symptoms consistent with acute coronary syndrome, particularly if she is peripartum. Furthermore, once suspected, it is imperative that a definitive diagnostic study, that is, coronary angiography, be completed prior to the initiation of treatment whenever possible.
View details for Web of Science ID 000236442200009
View details for PubMedID 16649728