[Show abstract][Hide abstract] ABSTRACT: Biomarkers can help to identity acute heart failure (AHF) as the cause of symptoms in patients presenting to the emergency department (ED). Older patients may prove a diagnostic challenge due to co-morbidities. Therefore we prospectively investigated the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) alone or in combination with other biomarkers for AHF upon admission at the ED.
European heart journal. Acute cardiovascular care. 07/2014;
[Show abstract][Hide abstract] ABSTRACT: Quantitative measurements of coronary plaque volume may play a role in serial studies to determine disease progression or regression. Our aim was to evaluate the interscan reproducibility of quantitative measurements of coronary plaque volumes using a standardized automated method.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the image quality and diagnostic accuracy of very low-dose computed tomography (CT) angiography (CTA) for the evaluation of coronary artery stenosis.
[Show abstract][Hide abstract] ABSTRACT: Recent studies have shown a significant correlation between increased epicardial fat volume (EFV) and mortality, coronary artery disease events, and measures of coronary atherosclerotic burden, for example, coronary calcium. Patients with chronic kidney disease on hemodialysis have an increased prevalence of coronary atherosclerosis and coronary calcium. The mechanisms underlying both may differ from patients with normal kidney function. Only limited data are available on the relationship between epicardial fat and coronary calcium in these patients.
[Show abstract][Hide abstract] ABSTRACT: Inflammation accelerates both plaque progression and instability in the pathogenesis of atherosclerosis. The inhibition of dendritic cell (DC) maturation is a promising approach to suppress excessive inflammatory immune responses and has been shown to be protective in several autoimmune models. The aim of this study was to investigate the immune modulatory effects of the natural substance MCS-18, an inhibitor of DC maturation, regarding the progression of atherosclerosis in ApoE-deficient mice.
[Show abstract][Hide abstract] ABSTRACT: Prior studies evaluating the prognostic utility of cardiac CT angiography (CCTA) have been largely constrained to an all-cause mortality endpoint, with other cardiac endpoints generally not reported. To this end, we sought to determine the relationship of extent and severity of coronary artery disease (CAD) by CCTA to risk of incident major adverse cardiac events (MACEs) (defined as death, myocardial infarction, and late revascularization).
We identified subjects without prior known CAD who underwent CCTA and were followed for MACE. CAD by CCTA was defined as none (0% luminal stenosis), mild (1-49% luminal stenosis), moderate (50-69% luminal stenosis), or severe (≥70% luminal stenosis), and ≥50% luminal stenosis was considered as obstructive. CAD severity was judged on per-patient, per-vessel, and per-segment basis. Time to MACE was estimated using univariable and multivariable Cox proportional hazards models. Among 15 187 patients (57 ± 12 years, 55% male), 595 MACE events (3.9%) occurred at a 2.4 ± 1.2 year follow-up. In multivariable analyses, an increased risk of MACE was observed for both non-obstructive [hazard ratio (HR) 2.43, P < 0.001] and obstructive CAD (HR: 11.21, P < 0.001) when compared with patients with normal CCTA. Risk-adjusted MACE increased in a dose-response relationship based on the number of vessels with obstructive CAD ≥50%, with increasing hazards observed for non-obstructive (HR: 2.54, P < 0.001), obstructive one-vessel (HR: 9.15, P < 0.001), two-vessel (HR: 15.00, P < 0.001), or three-vessel or left main (HR: 24.53, P < 0.001) CAD. Among patients stratified by age <65 vs. ≥65 years, older individuals experienced higher risk-adjusted hazards for MACE for non-obstructive, one-, and two-vessel, with similar event rates for three-vessel or left main (P < 0.001 for all) compared with normal individuals age <65. Finally, there was a dose relationship of CAD findings by CCTA and MACE event rates with each advancing decade of life.
Among individuals without known CAD, non-obstructive, and obstructive CAD are associated with higher MACE rates, with different risk profiles based on age.
European heart journal cardiovascular Imaging. 05/2014; 15(5):586-94.
[Show abstract][Hide abstract] ABSTRACT: Coronary artery calcium (CAC) is a well-established predictor of clinical outcomes for population screening. Limited evidence is available as to its predictive value in symptomatic patients without obstructive coronary artery disease (CAD). The aim of the current study was to assess the prognostic value of CAC scores among symptomatic patients with nonobstructive CAD.
From the COronary Computed Tomographic Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 7,200 symptomatic patients with nonobstructive CAD (<50% coronary stenosis) on coronary-computed tomographic angiography were prospectively enrolled and followed for a median of 2.1 years. Patients were categorized as without (0% stenosis) or with (>0% but <50% coronary stenosis) a luminal stenosis. CAC scores were calculated using the Agatston method. Univariable and multivariable Cox proportional hazard models were employed to estimate all-cause mortality and/or myocardial infarction (MI). Four-year death and death or MI rates were 1.9% and 3.3%.
Of the 4,380 patients with no luminal stenosis, 86% had CAC scores of <10 while those with a luminal stenosis had more prevalent and extensive CAC with 31.9% having a CAC score of ≥100. Among patients with no luminal stenosis, CAC was not predictive of all-cause mortality (P = .44). However, among patients with a luminal stenosis, 4-year mortality rates ranged from 0.8% to 9.8% for CAC scores of 0 to ≥400 (P < .0001). The mortality hazard was 6.0 (P = .004) and 13.3 (P < .0001) for patients with a CAC score of 100-399 and ≥400. In patients with a luminal stenosis, CAC remained independently predictive in all-cause mortality (P < .0001) and death or MI (P < .0001) in multivariable models containing CAD risk factors and presenting symptoms.
CAC allows for the identification of those at an increased hazard for death or MI in symptomatic patients with nonobstructive disease. From the CONFIRM registry, the extent of CAC was an independent estimator of long-term prognosis among symptomatic patients with luminal stenosis and may further define risk and guide preventive strategies in patients with nonobstructive CAD.
Journal of Nuclear Cardiology 03/2014; · 2.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is a growing interest from the scientific community in the appropriate use of cardiovascular imaging techniques for diagnosis and decision making in Europe. To develop appropriateness criteria for cardiovascular imaging use in clinical practice in Europe, a dedicated taskforce has been appointed by the European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI). The present paper describes the appropriateness criteria development process.
European heart journal cardiovascular Imaging. 03/2014;
[Show abstract][Hide abstract] ABSTRACT: To systematically review and perform a meta-analysis of the diagnostic accuracy and post-test outcomes of conventional exercise electrocardiography (XECG) and single-photon emission computed tomography (SPECT) compared with coronary computed tomography angiography (coronary CTA) in patients suspected of stable coronary artery disease (CAD).
We systematically searched for studies published from January 2002 to February 2013 examining the diagnostic accuracy (defined as at least ≥50% luminal obstruction on invasive coronary angiography) and outcomes of coronary CTA (≥16 slice) in comparison with XECG and SPECT. The search revealed 11 eligible studies (N = 1575) comparing the diagnostic accuracy and 7 studies (N = 216.603) the outcomes of coronary CTA vs. XECG or/and SPECT. The per-patient sensitivity [95% confidence interval (95% CI)] to identify significant CAD was 98% (93-99%) for coronary CTA vs. 67% (54-78%) (P < 0.001) for XECG and 99% (96-100%) vs. 73% (59-83%) (P = 0.001) for SPECT. The specificity (95% CI) of coronary CTA was 82% (63-93%) vs. 46% (30-64%) (P < 0.001) for XECG and 71% (60-80%) vs. 48% (31-64%) (P = 0.14) for SPECT. The odds ratio (OR) of downstream test utilization (DTU) for coronary CTA vs. XECG/SPECT was 1.38 (1.33-1.43, P < 0.001), for revascularization 2.63 (2.50-2.77, P < 0.001), for non-fatal myocardial infarction 0.53 (0.39-0.72, P < 0.001), and for all-cause mortality 1.01 (0.87-1.18, P = 0.87).
The up-front diagnostic performance of coronary CTA is higher than of XECG and SPECT. When compared with XECG/SPECT testing, coronary CTA testing is associated with increased DTU and coronary revascularization.
European heart journal cardiovascular Imaging. 03/2014;
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Short-term risk scores, such as the Framingham risk score (FRS), frequently classify younger patients as low risk despite the presence of uncontrolled cardiovascular risk factors. Among patients with low FRS, estimation of lifetime risk is associated with significant differences in coronary arterial calcium scores (CACS); however, the relationship of lifetime risk to coronary atherosclerosis on coronary CT angiography (CCTA) and prognosis has not been studied.
METHODS AND RESULTS: We evaluated asymptomatic 20-60-year-old patients without diabetes or known coronary artery disease (CAD) within an international CT registry who underwent ≥64-slice CCTA. Patients with low FRS (<10%) were stratified as low (<39%) or high (≥39%) lifetime CAD risk, and compared for the presence and severity of CAD and prognosis for death, myocardial infarction, and late coronary revascularization (>90 days post CCTA). 1,863 patients of mean age of 47 years were included, with 48% of the low FRS patients at high lifetime risk. Median follow-up was 2.0 years. Comparing low-to-high lifetime risk, respectively, the prevalence of any CAD was 32% vs 41% (P < .001) and ≥50% stenosis was 7.4% vs 9.6% (P = .09). For those with CAD, subjects at low vs high lifetime risk had lower CACS (median 12 [IQR 0-94] vs 38 [IQR 0.05-144], P = .02) and less purely calcified plaque, 35% vs 45% (P < .001). Prognosis did not differ due to low number of events.
CONCLUSION: Assessment of lifetime risk among patients at low FRS identified those with the increase in CAD prevalence and severity and a higher proportion of calcified plaque.
Journal of Nuclear Cardiology 01/2014; 21(1):29-37. · 2.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose
We aimed to quantitatively characterize and compare coronary plaque burden from coronary CT Angiography (CTA) in patients with a first acute coronary syndrome (ACS) and controls with stable coronary artery disease.
Materials and Methods
We retrospectively analyzed consecutive patients with Non-ST-Segment Elevation Myocardial Infarction(NSTEMI) or unstable angina with a first ACS, who underwent CTA as part of their initial workup before invasive coronary angiography, and age-and-gender-matched controls with stable chest pain; controls also underwent CTA with subsequent invasive angiography (total n=28). Culprit arteries were identified in ACS patients. Coronary arteries were analyzed by automated software, to quantify calcified plaque (CP), non-calcified plaque (NCP) and low density NCP (LD-NCP, attenuation <30 HU) volumes, and corresponding burden (plaque volumex100%/vessel volume), stenosis, remodeling index (RI), contrast density difference (maximum %difference in attenuation/cross-sectional area from proximal cross-section), and plaque length.
ACS patients had fewer lesions (median 1), with higher total NCP and LD-NCP burdens (NCP:57.4% vs. 41.5%, LD-NCP:12.5% vs. 8%; p≤0.04), higher maximal stenoses (85.6% vs. 53.0%, p=0.003) and contrast density differences (46.1 vs 16.3%, p<0.006). Per-patient CP burden was not different between ACS and controls. NCP and LD-NCP plaque burden was higher in culprit vs. non-culprit arteries (NCP:57.8% vs 9.5%,LD-NCP:8.4% vs 0.6%, p≤0.0003); CP was not significantly different. Culprit arteries had increased plaque lengths, RIs, stenoses and contrast density differences (46.1% vs 10.9%, p≤0.001).
Noninvasive quantitative coronary artery analysis identified several differences for ACS, both on per-patient and per-vessel basis, including increased NCP, LD-NCP burden, and contrast density difference.
Journal of Cardiovascular Computed Tomography. 01/2014;
[Show abstract][Hide abstract] ABSTRACT: Objectives
To determine the diagnostic performance of non-invasive FFR derived from standard acquired coronary computed tomography angiography (CTA) datasets (FFRCT) for the diagnosis of myocardial ischemia in patients with suspected stable coronary artery disease (CAD).
Fractional flow reserve (FFR) measured during invasive coronary angiography (ICA) is the gold standard for lesion-specific coronary revascularization decisions in patients with stable CAD. The potential for FFRCT to non-invasively identify ischemia in patients with suspected CAD has not been sufficiently investigated.
This prospective multicenter trial included 254 patients scheduled to undergo clinically indicated ICA for suspected CAD. Coronary CTA was performed prior to ICA. Evaluation of stenosis (>50% lumen reduction) in coronary CTA was performed by local investigators and in ICA by an independent Core Laboratory. FFRCT was calculated and interpreted in a blinded fashion by an independent Core Laboratory. Results were compared to invasively measured FFR, with ischemia defined as FFRCT or FFR ≤0.80.
The area under the receiver operating characteristic curve (95% CI) for FFRCT was 0.90 (0.87-0.94) versus 0.81 (0.76-0.87) for coronary CTA (p=0.0008). Per-patient sensitivity and specificity to identify myocardial ischemia were 86% (95% CI: 77%-92%) and 79% (72%-84%) for FFRCT versus 94% (86%-97%) and 34% (27%-41%) for coronary CTA, and 65% (53%-74%) and 83% (77%-83%) for ICA, respectively. In patients (n=235) with intermediate stenosis (30%-70%) the diagnostic accuracy of FFRCT remained high.
FFRCT provides high diagnostic accuracy, and discrimination for the diagnosis of hemodynamically significant CAD with invasive FFR as the reference standard. When compared to anatomic testing by coronary CTA, FFRCT leads to a marked increase in specificity.
Clinical trial info
Journal of the American College of Cardiology 01/2014; · 14.09 Impact Factor