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Miller RJH, Patel KK, Kwiecinski J, Slipczuk L, Dweck M, Newby DE, Chareonthaitawee P, Slomka P. Nuclear Cardiology Surrogate Biomarkers in Clinical Trials. J Nucl Med 2025; 66:4-11. [PMID: 39753367 DOI: 10.2967/jnumed.124.267869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 12/05/2024] [Indexed: 02/20/2025] Open
Abstract
Nuclear cardiology offers a diverse range of imaging tools that provide valuable insights into myocardial perfusion, inflammation, metabolism, neuroregulation, thrombosis, and microcalcification. These techniques are crucial not only for diagnosing and managing cardiovascular conditions but also for gaining pathophysiologic insights. Surrogate biomarkers in nuclear cardiology, represented by detectable imaging changes, correlate with disease processes or therapeutic responses and can serve as endpoints in clinical trials when they demonstrate a clear link with these processes. By providing early indicators of therapeutic efficacy-often before clinical outcomes manifest-surrogate biomarkers can accelerate treatment development. This disease-focused review will highlight key nuclear cardiology surrogate biomarkers, emphasizing the importance of standardized imaging protocols and robust quantitative techniques to ensure accuracy and reproducibility. We will also explore the challenges to the broader adoption of imaging biomarkers, including the need for well-defined pathophysiologic correlations, greater data diversity in clinical research, and overcoming regulatory barriers. Addressing these challenges will improve the utility of imaging biomarkers in clinical trials, enabling more precise cardiovascular care through early diagnosis and therapeutic monitoring, ultimately accelerating the development of novel cardiovascular therapies.
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Affiliation(s)
- Robert J H Miller
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Krishna K Patel
- Department of Medicine (Cardiology) and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | | | - Marc Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; and
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; and
| | | | - Piotr Slomka
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California;
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Nogami K, Hoshino M, Usui E, Kanaji Y, Sugiyama T, Hada M, Nagamine T, Ueno H, Setoguchi M, Tahara T, Sakamoto T, Mineo T, Kakuta T. Prognostic value of global coronary flow reserve before and after elective percutaneous coronary intervention in patients with chronic coronary syndrome. J Cardiovasc Magn Reson 2024; 26:101106. [PMID: 39332709 DOI: 10.1016/j.jocmr.2024.101106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Revised: 08/25/2024] [Accepted: 09/21/2024] [Indexed: 09/29/2024] Open
Abstract
BACKGROUND Impaired global coronary flow reserve (G-CFR), evaluated through phase-contrast cine cardiovascular magnetic resonance (PC-CMR), has been linked to worse outcomes in patients with cardiovascular disease. This study aimed to investigate the prognostic value of G-CFR improvement, as evaluated using PC-CMR imaging pre- and post-percutaneous coronary intervention (PCI). METHODS In this single-center study, 320 patients with chronic coronary syndrome (CCS) who underwent pre- and post-PCI PC-CMR measurements were followed up to determine major adverse cardiac or cerebrovascular events (MACCE) predictors. MACCE was defined as a composite of cardiac death, nonfatal myocardial infarction, hospitalization due to heart failure, or ischemic stroke. The association between CMR parameters, including baseline data, G-CFR changes post-PCI, and MACCE, was investigated. RESULTS G-CFR improvement was observed in 51.6% (165/320) patients, while MACCE occurred in 8.1% (26/320) during a median follow-up period of 2.5 years. G-CFR improvement was significantly associated with a lower pre-PCI G-CFR. The log-rank test revealed a significant association between patients without G-CFR improvement post-PCI and a poor prognosis. Patients with lower pre-PCI G-CFR and lack of G-CFR improvement exhibited the highest incidence of MACCE. The multivariable Cox proportional hazard model revealed that lack of G-CFR improvement was an independently significant MACCE predictor from pre-PCI G-CFR and SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score. CONCLUSION Besides the association between pre- and post-PCI lower G-CFR and worse prognosis, the presence or absence of G-CFR improvement post-PCI may provide novel insights into the prognosis following elective PCI in patients with CCS.
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Affiliation(s)
- Kai Nogami
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tomoyo Sugiyama
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tatsuhiro Nagamine
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Hiroki Ueno
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Mirei Setoguchi
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tomohiro Tahara
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tatsuya Sakamoto
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Takashi Mineo
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura City, Ibaraki, Japan.
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Assante R, Zampella E, D'Antonio A, Mannarino T, Gaudieri V, Nappi C, Arumugam P, Panico M, Buongiorno P, Petretta M, Cuocolo A, Acampa W. Impact on cardiovascular outcome of coronary revascularization-induced changes in ischemic perfusion defect and myocardial flow reserve. Eur J Nucl Med Mol Imaging 2024; 51:1612-1621. [PMID: 38191816 PMCID: PMC11043198 DOI: 10.1007/s00259-023-06588-4] [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] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE We evaluated the impact on cardiovascular outcome of coronary revascularization-induced changes in ischemic total perfusion defect (ITPD) and myocardial flow reserve (MFR) as assessed by 82Rb positron emission tomography (PET)/computed tomography (CT) imaging. METHODS The study included 102 patients referred to 82Rb PET/CT myocardial perfusion imaging before and after coronary revascularization. All patients were followed for the occurrence of cardiovascular events (cardiac death, nonfatal myocardial infarction, repeated revascularization, and heart failure) after the second imaging study. RESULTS During a median follow-up of 20 months, 21 events occurred. The clinical characteristics were comparable between patients with and without events. In the overall study population, after revascularization, there was a significant reduction (P < 0.001) of ITPD, while hyperemic myocardial blood flow (MBF) (P < 0.01) and MFR (P < 0.05) significantly improved. Event rate was higher in patients with ITPD (P < 0.005) or MFR (P < 0.001) worsening compared to those with unchanged or improved ITPD or MFR. At Cox univariable analysis, ITPD and MFR worsening resulted in predictors of events (both P < 0.05). Patients with worsening of both ITPD and MFR had the worst event-free survival (log-rank 32.9, P for trend < 0.001). CONCLUSIONS In patients with stable CAD, worsening of ITPD and MFR after revascularization procedures is associated with higher risk of cardiovascular events. Follow-up MPI with 82Rb PET/CT may improve risk stratification in patients submitted to coronary revascularization.
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Affiliation(s)
- Roberta Assante
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Adriana D'Antonio
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Teresa Mannarino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Valeria Gaudieri
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Parthiban Arumugam
- Department of Nuclear Medicine, Central Manchester Foundation Trust, Manchester, UK
| | | | - Pietro Buongiorno
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | | | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy.
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Santos LDM, Campos CM, Garcia-Garcia HM, Godinho RR, Lopes MAAM, Seleme VB, Côrtes RS, Mendes GDAC, Rosa VEE, Lopes NHM, de Brito Junior FS, Abizaid AAC. Concordance between vessel-specific and vascular territory coronary functional assessment: A comparison of quantitative flow ratio and myocardial perfusion scintigraphy. Catheter Cardiovasc Interv 2024; 103:873-884. [PMID: 38558510 DOI: 10.1002/ccd.31021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/14/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Quantitative flow ratio (QFR) and myocardial perfusion scintigraphy (MPS) are utilized for assessing coronary artery disease (CAD) significance. We aimed to analyze their concordance and prognostic impact. AIMS We aimed to analyze the concordance between QFR and MPS and their risk stratification. METHODS Patients with invasive coronary angiography and MPS were categorized as concordant if QFR ≤ 0.80 and summed difference score (SDS) ≥ 4 or if QFR > 0.80 and SDS < 4; otherwise, they were discordant. Concordance was classified by coronary territory involvement: total (three territories), partial (two territories), poor (one territory), and total discordance (zero territories). Leaman score assessed coronary atherosclerotic burden. RESULTS 2010 coronary territories (670 patients) underwent joint QFR and MPS analysis. MPS area under the curve for QFR ≤ 0.80 was 0.637. Concordance rates were total (52.5%), partial (29.1%), poor (15.8%), and total discordance (2.6%). Most concordance occurred in patients without significant CAD or with single-vessel disease (89.5%), particularly without MPS perfusion defects (91.5%). Leaman score (odds ratio [OR]: 0.839, 95% confidence interval [CI]: 0.805-0.875, p < 0.001) and MPS perfusion defect (summed stress score [SSS] ≥ 4) (OR: 0.355, 95% CI: 0.211-0.596, p < 0.001) were independent predictors for discordance. After 1400 days, no significant difference in death/myocardial infarction was observed based on MPS assessment, but Leaman score, functional Leaman score, and average QFR identified higher risk patients. CONCLUSIONS MPS showed good overall accuracy in assessing QFR significance but substantial discordance existed. Predictors for discordance included higher atherosclerotic burden and MPS perfusion defects (SSS ≥ 4). Leaman score, QFR-based functional Leaman score, and average QFR provided better risk stratification for all-cause death and myocardial infarction than MPS.
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Affiliation(s)
- Luciano de Moura Santos
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
- Department of Interventional Cardiology, Hospital Santa Lucia, Brasilia, Brazil
| | - Carlos M Campos
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
- Instituto Prevent Senior, Sao Paulo, Brazil
| | - Hector Manuel Garcia-Garcia
- Instituto Prevent Senior, Sao Paulo, Brazil
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | | | | | | | - Rafael Silva Côrtes
- Department of Interventional Cardiology, Hospital Santa Lucia, Brasilia, Brazil
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Cheng Z, Wang Y, Liu J, Ming Y, Yao Y, Wu Z, Guo Y, Du L, Yan M. A novel model for predicting a composite outcome of major complications after valve surgery. Front Cardiovasc Med 2023; 10:1132428. [PMID: 37265563 PMCID: PMC10229809 DOI: 10.3389/fcvm.2023.1132428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
Background On-pump valve surgeries are associated with high morbidity and mortality. The present study aimed to reliably predict a composite outcome of postoperative complications using a minimum of easily accessible clinical parameters. Methods A total of 7,441 patients who underwent valve surgery were retrospectively analyzed. Data for 6,220 patients at West China Hospital of Sichuan University were used to develop a predictive model, which was validated using data from 1,221 patients at the Second Affiliated Hospital of Zhejiang University School of Medicine. The primary outcome was a composite of major complications: all-cause death in hospital, stroke, myocardial infarction, and severe acute kidney injury. The predictive model was constructed using the least absolute shrinkage and selection operator as well as multivariable logistic regression. The model was assessed in terms of the areas under receiver operating characteristic curves, calibration, and decision curve analysis. Results The primary outcome occurred in 129 patients (2.1%) in the development cohort and 71 (5.8%) in the validation cohort. Six variables were retained in the predictive model: New York Heart Association class, diabetes, glucose, blood urea nitrogen, operation time, and red blood cell transfusion during surgery. The C-statistics were 0.735 (95% CI, 0.686-0.784) in the development cohort and 0.761 (95% CI, 0.694-0.828) in the validation cohort. For both cohorts, calibration plots showed good agreement between predicted and actual observations, and ecision curve analysis showed clinical usefulness. In contrast, the well-established SinoSCORE did not accurately predict the primary outcome in either cohort. Conclusions This predictive nomogram based on six easily accessible variables may serve as an "early warning" system to identify patients at high risk of major complications after valve surgery. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [NCT04476134].
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Affiliation(s)
- Zhenzhen Cheng
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yishun Wang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jing Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanyuan Yao
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhong Wu
- Department of Cardiovascular Surgery of West China Hospital, Sichuan University, Chengdu, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery of West China Hospital, Sichuan University, Chengdu, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Hage FG, Einstein AJ, Ananthasubramaniam K, Bourque JM, Case J, DePuey EG, Hendel RC, Henzlova MJ, Shah NR, Abbott BG, Al Jaroudi W, Better N, Doukky R, Duvall WL, Malhotra S, Pagnanelli R, Peix A, Reyes E, Saeed IM, Sanghani RM, Slomka PJ, Thompson RC, Veeranna V, Williams KA, Winchester DE. Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement. J Nucl Cardiol 2023; 30:864-907. [PMID: 36607538 DOI: 10.1007/s12350-022-03162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Fadi G Hage
- Section of Cardiology, Birmingham VA Medical Center, Birmingham, AL, USA.
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 446 GSB, 520 19Th Street South, Birmingham, AL, 35294, USA.
| | - Andrew J Einstein
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine and Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Jamieson M Bourque
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, VA, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - James Case
- Cardiovascular Imaging Technologies, Kansas City, MO, USA
| | - E Gordon DePuey
- Mount Sinai Morningside Hospital, New York, NY, USA
- Bay Ridge Medical Imaging, Brooklyn, NY, USA
| | - Robert C Hendel
- Department of Medicine, Division of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Nishant R Shah
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Brian G Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Wael Al Jaroudi
- Division of Cardiovascular Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nathan Better
- Department of Nuclear Medicine and Cardiology, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Rami Doukky
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | | | - Amalia Peix
- Nuclear Medicine Department, Institute of Cardiology and Cardiovascular Surgery, La Habana, Cuba
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ibrahim M Saeed
- Virginia Heart, Falls Church, VA, USA
- INOVA Heart and Vascular Institute, Falls Church, VA, USA
- University of Missouri, Kansas City, MO, USA
| | - Rupa M Sanghani
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vikas Veeranna
- Division of Cardiology, Department of Medicine, New England Heart and Vascular Institute, Manchester, NH, USA
| | - Kim A Williams
- Department of Medicine, University of Louisville Department of Medicine, Louisville, KY, USA
| | - David E Winchester
- Malcom Randall VA Medical Center, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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Tottleben J, Howland J, Rofael M, Co MLF, Torres A, Doukky R. The prognostic and diagnostic implications of surveillance serial myocardial perfusion imaging in asymptomatic renal transplant candidates. J Nucl Cardiol 2023; 30:152-163. [PMID: 35705845 DOI: 10.1007/s12350-022-03017-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The utility of serial SPECT myocardial perfusion imaging (MPI) for CAD surveillance in asymptomatic ESRD patients awaiting kidney transplantation (KT) is uncertain. METHODS AND RESULTS We retrospectively investigated 700 asymptomatic KT candidates with ≥ 2 pre-transplant SPECT-MPIs (mean interval, 20 ± 13 months). Worsening MPI was defined as total perfusion deficit increase (ΔTPD) > 5%. High clinical risk was defined as ≥ 3 AHA/ACC KT risk factors. The primary outcome was major adverse cardiac events (MACE) of cardiac death or myocardial infarction. The initial MPI was normal in 462 (66%) subjects. On repeat MPI, ΔTPD > 5% was observed in 82 (12%) subjects, and the incidence increased with increasing time gap between MPIs (P = .006). During a mean follow-up of 16 ± 8 months, there were 119 (17%) MACEs. In the entire cohort, ΔTPD > 5% was not significantly associated with MACE (HR = 1.38; P = .210). ΔTPD > 5% was associated with increased MACE rate among patients with normal initial MPI (HR = 2.30; P = .005), but not among those with abnormal initial MPI (P = .260). There was a significant interaction between ΔTPD > 5% and initial MPI normalcy status in predicting MACE (interaction P = .018), such that the predictive value of ΔTPD is dependent on the initial MPI normalcy. Among subjects with normal initial MPI, ΔTPD > 5% was significantly associated with MACE only if the sum of KT risk factors was ≥ 3 (HR = 2.26; P = .016). Among 123 patients who underwent coronary angiography, ΔTPD > 5% was associated with a higher prevalence of obstructive CAD when the initial MPI was normal and the sum of KT risk factors was ≥ 3. CONCLUSION Among patients with ESRD waitlisted for KT, new/worsening MPI abnormalities are expected. On serial surveillance, ΔTPD > 5% is associated with MACE and obstructive CAD among those with a normal initial MPI and ≥ 3 AHA/ACC KT risk factors.
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Affiliation(s)
- Jonathan Tottleben
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Julia Howland
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael Rofael
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | | | - Andrea Torres
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, 1901 W. Harrison Street, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Ansheles AA. [The Revival of the "Ischemic" Approach in the Assessment of Ischemic Heart Disease: Analysis of Major World Research]. KARDIOLOGIIA 2023; 63:60-67. [PMID: 36749203 DOI: 10.18087/cardio.2023.1.n1478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/31/2020] [Accepted: 02/26/2021] [Indexed: 02/08/2023]
Abstract
This analytical review focuses on large international studies on diagnostics of ischemic heart disease and addresses the role of radionuclide methods in evaluating myocardial perfusion and transient ischemia. Based on the reviewed data, the authors proposed a comprehensive instrumental approach to selecting a tactics for the management of patients with suspected or documented ischemic heart disease and for evaluating their prognosis.
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Affiliation(s)
- A A Ansheles
- Chazov National Medical Research Center of Cardiology, Moscow
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9
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Assante R, Zampella E, Acampa W. Advanced technology in the risk stratification-based strategy: The way forward to keep going. J Nucl Cardiol 2021; 28:2937-2940. [PMID: 32533425 DOI: 10.1007/s12350-020-02198-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Roberta Assante
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Emilia Zampella
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Wanda Acampa
- Department of Advanced Biomedical Sciences, University Federico II, Via Pansini 5, 80131, Naples, Italy.
- Institute of Biostructure and Bioimaging, National Council of Research, Naples, Italy.
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Mahmoudi M, Nicholas Z, Nuttall J, Bresser M, Maishman T, Berry C, Hlatky MA, Douglas P, Rajani R, Fox K, Curzen N. Fractional Flow Reserve Derived from Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain: Rationale and Design of the FORECAST Trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:890-896. [DOI: 10.1016/j.carrev.2019.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/23/2019] [Accepted: 12/03/2019] [Indexed: 11/28/2022]
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Ansheles AA, Sergienko IV, Denisenko-Kankiya EI, Sergienko VB. [Myocardial perfusion single-photon emission computer tomography and coronary angiography results in patients with different pretest probability of ischemic heart disease]. TERAPEVT ARKH 2020; 92:30-36. [PMID: 32598695 DOI: 10.26442/00403660.2020.04.000549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Indexed: 11/22/2022]
Abstract
AIM To study the relationship between pretest probability (PTP) of ischemic heart disease (IHD), calculated according to the recommendations of the European Society of Cardiology (ESC) of 2013 and 2019, with the perfusion of the left ventricle of the myocardium according to the single-photon emission tomography (SPECT) and the results of the invasive coronary angiography (CAG). MATERIAL AND METHODS The study included 220 patients with a preliminary diagnosis of ischemic heart disease and planned invasive CAG. All patients underwent rest-stress perfusion myocardial SPECT within 1 month prior to or after CAG, standard quantitative parameters of left ventricular perfusion were assessed. Retrospectively clinical data was analyzed and PTP of IHD was assessed according to ESC recommendations for 2013 and 2019. RESULTS Invasive CAG revealed obstructive lesion of one or more coromary arteries in 204 of the 220 patients (92.7%). In a retrospective analysis, taking into account gender, age and nature of the complaints, as recommended by ESC in 2013, PTP was rated as low (15%) in 13 patients (5.9%), as intermediate (1585%) in 207 patients (94.1%). Following the comprehensive survey (SPECT and CAG) 8 patients with low PTP (61.5%) underwent coronary revascularization. Among patients with intermediate PTP significant transient ischemia according to SPECT was detected in 31 (15.0%), initial at 107 (51.7%). According CAG among patients with intermediate PTP obstructive lesion was found in 192 (92.7%), 113 patients (58.8%) underwent revascularization. According to ESC recommendations of 2019, PTP was rated as low (15%) in 117 patients (53.2%), including 514% in 98 (44.5%). According to a survey (SPECT and CAG) 68 of them (58.1%) underwent revascularization. CONCLUSION PTP measurements proposed by ESC can not be applied to patients of the Russian population with suspected ischemic heart disease without significant corrections. 2013 ESC recommendations with higher PTP values for all categories of patients reflect Russian population better, while 2019 recommendations mistakenly attribute patients to low PTP in at least 58% of cases. These results are preliminary and will be expanded in subsequent studies with more detailed analysis of PTP in included patients with suspected IHD.
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Ganyukov V, Kochergin N, Shilov A, Tarasov R, Skupien J, Szot W, Kokov A, Popov V, Kozyrin K, Barbarash O, Barbarash L, Musialek P. Randomized Clinical Trial of Surgical vs. Percutaneous vs. Hybrid Revascularization in Multivessel Coronary Artery Disease: Residual Myocardial Ischemia and Clinical Outcomes at One Year-Hybrid coronary REvascularization Versus Stenting or Surgery (HREVS). J Interv Cardiol 2020; 2020:5458064. [PMID: 31969796 PMCID: PMC6961598 DOI: 10.1155/2020/5458064] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 09/09/2019] [Indexed: 11/17/2022] Open
Abstract
AIM Optimal revascularization strategy in multivessel (MV) coronary artery disease (CAD) eligible for percutaneous management (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR), or MV-PCI. METHODS Consecutive MV-CAD patients (n = 155) were randomized (1 : 1 : 1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization midterm efficacy and an independent predictor of long-term prognosis) preceded routine angiographic control. RESULTS Data are given, respectively, for the CABG, HCR, and MV-PCI arms. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.71). Hospital stay was 13.8 vs. 13.5 vs. 4.5 days (p < 0.001), and sick-leave duration was 23 vs. 16 vs. 8 weeks (p < 0.001). At 12 months, RI was 5 (2, 9)% vs. 5 (3, 7)% vs. 6 (3, 10)% (median; Q1, Q3) with noninferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). Rates of angiographic graft stenosis/occlusion or in-segment restenosis were 20.4% vs. 8.2% vs. 5.9% (p=0.05). Clinical target vessel/graft failure occurred in 12.0% vs. 11.5% vs. 11.3% (p=0.62). Major adverse cardiac and cerebral event (MACCE) rate was similar (12% vs. 13.4% vs. 13.2%; p=0.83). CONCLUSION In this first randomized controlled study comparing CABG, HCR, and MV-PCI, residual myocardial ischemia and MACCE were similar at 12 months. There was no midterm indication of any added value of HCR. Hospital stay and sick-leave duration were shortest with MV-PCI. While longer-term follow-up is warranted, these findings may impact patient and physician choices and healthcare resources utilization. This trial is registered with NCT01699048.
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Affiliation(s)
- Vladimir Ganyukov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Nikita Kochergin
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Aleksandr Shilov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Roman Tarasov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Jan Skupien
- Jagiellonian University School of Medicine, Krakow, Poland
| | - Wojciech Szot
- Jagiellonian University School of Medicine, Krakow, Poland
- Dept. of Nuclear Medicine, John Paul II Hospital, Krakow, Poland
| | - Aleksandr Kokov
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Vadim Popov
- Federal State Budgetary Institution A. V. Vishnevsky Institute of Surgery, Moscow, Russia
| | - Kirill Kozyrin
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Olga Barbarash
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Leonid Barbarash
- Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russia
| | - Piotr Musialek
- Jagiellonian University School of Medicine, Krakow, Poland
- Jagiellonian University Dept. of Cardiac & Vascular Diseases, John Paul II Hospital, Krakow, Poland
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Sex-Specific Association Between Coronary Artery Disease Severity and Myocardial Ischemia Induced by Mental Stress. Psychosom Med 2019; 81:57-66. [PMID: 30571661 PMCID: PMC6800112 DOI: 10.1097/psy.0000000000000636] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE It is unclear whether mental stress-induced myocardial ischemia (MSIMI) is related to obstructive coronary artery disease (CAD). We examined this question and contrasted results with ischemia induced by conventional stress testing (CSIMI). Because women are more susceptible to ischemia without coronary obstruction than men, we examined sex differences. METHODS We studied 276 patients 61 years and younger with recent myocardial infarction. CAD severity was quantified using the log-transformed Gensini Score (lnGS) and the Sullivan Stenosis Score. Patients underwent myocardial perfusion imaging with mental stress (public speaking) and conventional (exercise or pharmacological) stress testing. MSIMI and CSIMI were defined as a new or worsening perfusion defect. RESULTS The prevalence of MSIMI was 15% in men and 20% in women. The median GS for patients with MSIMI was 65.0 in men and 28.5 in women. In logistic regression models adjusted for demographic and cardiovascular risk factors, CAD severity was associated with CSIMI in the full sample (odds ratio [OR] = 1.49, 95% [CI], 1.14-1.95, per 1-unit increase in lnGS), with no significant difference by sex. Although CAD severity was not associated with MSIMI in the entire sample, results differed by sex. CAD severity was associated with MSIMI among men (OR = 1.95, 95% CI, 1.13-3.36, per 1-unit increase in lnGS), but not among women (OR = 1.02, 95% CI, 0.74-1.42, p = .042 for interaction). Analysis using Sullivan Stenosis Score yielded similar results. CONCLUSIONS Findings suggest that CAD severity is related to MSIMI in men but not women. MSIMI in women may therefore be driven by alternative mechanisms such as coronary microvascular disease.
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14
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Redfors B, Chen S, Crowley A, Ben-Yehuda O, Gersh BJ, Lembo NJ, Brown WM, Banning AP, Taggart DP, Serruys PW, Kappetein AP, Sabik JF, Stone GW. B-Type Natriuretic Peptide Assessment in Patients Undergoing Revascularization for Left Main Coronary Artery Disease. Circulation 2018; 138:469-478. [DOI: 10.1161/circulationaha.118.033631] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Elevated B-type natriuretic peptide (BNP) is reflective of impaired cardiac function and is associated with worse prognosis among patients with coronary artery disease (CAD). We sought to assess the association between baseline BNP, adverse outcomes, and the relative efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with left main CAD.
Methods:
The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and low or intermediate SYNTAX scores (Synergy Between PCI With TAXUS and Cardiac Surgery) to PCI with everolimus-eluting stents versus CABG. The primary end point was the composite of all-cause death, myocardial infarction, or stroke. We used multivariable Cox proportional hazards regression to assess the associations between normal versus elevated BNP (≥100 pg/mL), randomized treatment, and the 3-year risk of adverse events.
Results:
BNP at baseline was elevated in 410 of 1037 (39.5%) patients enrolled in EXCEL. Patients with elevated BNP levels were older and more frequently had additional cardiovascular risk factors and lower left ventricular ejection fraction than those with normal BNP, but had similar SYNTAX scores. Patients with elevated BNP had significantly higher 3-year rates of the primary end point (18.6% versus 11.7%; adjusted hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.16–2.28;
P
=0.005) and higher mortality (11.5% versus 3.9%; adjusted HR, 2.49; 95% CI, 1.48–4.19;
P
=0.0006), both from cardiovascular and noncardiovascular causes. In contrast, there were no significant differences in the risks of myocardial infarction, stroke, ischemia-driven revascularization, stent thrombosis, graft occlusion, or major bleeding. A significant interaction (
P
interaction
=0.03) was present between elevated versus normal BNP and treatment with PCI versus CABG for the adjusted risk of the primary composite end point at 3 years among patients with elevated BNP (adjusted HR for PCI versus CABG, 1.54; 95% CI, 0.96–2.47) versus normal BNP (adjusted HR, 0.74; 95% CI, 0.46–1.20). This interaction was stronger when log(BNP) was modeled as a continuous variable (
P
interaction
=0.002).
Conclusions:
In the EXCEL trial, elevated baseline BNP levels in patients with left main CAD undergoing revascularization were independently associated with long-term mortality but not nonfatal adverse ischemic or bleeding events. The relative long-term outcomes after PCI versus CABG for revascularization of left main CAD may be conditioned by the baseline BNP level.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01205776.
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Affiliation(s)
- Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (B.J.G.)
| | - Nicholas J. Lembo
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
| | | | | | - David P. Taggart
- John Radcliffe Hospital, Oxford, United Kingdom (A.P.B., D.P.T.)
| | - Patrick W. Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom (P.W.S.)
| | | | - Joseph F. Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | - Gregg W. Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
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15
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Should functional assessment of lesion severity be used to guide coronary bypass? Curr Opin Cardiol 2018; 33:565-570. [PMID: 29994809 DOI: 10.1097/hco.0000000000000549] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to investigate the potential role of fractional flow reserve (FFR) to guide surgical revascularization. RECENT FINDINGS Coronary artery bypass is planned and executed primarily based on angiographic coronary anatomy. FFR is the most well-established tool for functional assessment of coronary lesions. Randomized trials have demonstrated the benefit of FFR-guided percutaneous coronary intervention (PCI) to determine the ischemic burden of intermediate lesions. Surgically, FFR is predominantly used to determine the functional severity of intermediate lesions of the left anterior descending (LAD) coronary artery to establish candidacy for multivessel coronary bypass. The broader use of FFR will likely downgrade a proportion of coronary lesions, which may alter the overall management plan. Whether this will improve clinical outcomes remains to be seen. Importantly, bypass of functionally nonsignificant lesions predicts graft failure. However, graft failure in the context of sufficient native coronary flow may not impact negatively on clinical outcome. Thus, at this time, there are insufficient data to support the wider use of FFR to guide surgical grafting of non-LAD targets. It remains to be seen whether FFR can be used to optimize the use of arterial grafts or to guide complex revascularization strategies such as hybrid coronary revascularization. SUMMARY FFR has become an invaluable tool for decision making for PCI in patients with stable ischemic heart disease. Beyond its use to assess an intermediate LAD lesion to establish candidacy for coronary bypass, at present there are insufficient data to support its wider use to guide surgical revascularization.
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16
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Magnetic Resonance Perfusion Imaging to Guide Management of Patients With Stable Ischemic Heart Disease. JACC Cardiovasc Imaging 2018; 11:997-999. [PMID: 29976306 DOI: 10.1016/j.jcmg.2018.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 01/09/2023]
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17
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Nudi F, Di Belardino N, Versaci F, Pinto A, Procaccini E, Neri G, Vetere M, Frati G, Peruzzi M, Schillaci O, Gaspardone A, Tomai F, Biondi-Zoccai G. Impact of coronary revascularization vs medical therapy on ischemia among stable patients with or suspected coronary artery disease undergoing serial myocardial perfusion scintigraphy. J Nucl Cardiol 2017; 24:1690-1698. [PMID: 27229341 DOI: 10.1007/s12350-016-0504-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/03/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Randomized trials have challenged the role of revascularization in stable coronary artery disease. We aimed to appraise the impact of revascularization on ischemia in patients undergoing serial myocardial perfusion scintigraphy (MPS). METHODS We queried our institutional database for stable subjects undergoing serial MPS and appraised the impact of revascularization on changes in ischemia. RESULTS A total of 3631 patients were included: 967 (27%) undergoing revascularization and 2664 (73%) receiving medical therapy only. Patients treated with revascularization had a significantly lower burden of myocardial ischemia at follow-up (odds ratio = 0.577 [95% confidence interval 0.483-0.689] vs medical therapy, P < .001). Among all those having moderate or severe ischemia at baseline, revascularization was associated with a follow-up prevalence of 80% for no, minimal, or mild ischemia and 20% for moderate or severe ischemia, vs 43% and 57% for medical therapy (P < .001). Even at multivariable analysis and propensity-adjusted, and propensity-matched analyses, revascularization was associated with a significantly lower prevalence of moderate or severe ischemia at follow-up (respectively P < .001, P = .001, and P = .042). CONCLUSIONS Revascularization appears superior to medical therapy in reducing ischemic burden and normalizing myocardial perfusion among subjects with moderate or severe ischemia at baseline.
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Affiliation(s)
- Francesco Nudi
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Rome, Italy
- Ostia Radiologica, Rome, Italy
- Etisan, Rome, Italy
| | | | - Francesco Versaci
- Department of Cardiovascular Disease, Ospedale A. Cardarelli, Campobasso, Italy
- Department of Cardiovascular Disease, Ospedale F. Veneziale, Isernia, Italy
| | - Annamaria Pinto
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Rome, Italy
| | - Enrica Procaccini
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Rome, Italy
| | - Giandomenico Neri
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Rome, Italy
| | - Maurizio Vetere
- Service of Nuclear Cardiology, Madonna della Fiducia Clinic, Rome, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100, Latina, Italy
- Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
| | - Mariangela Peruzzi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100, Latina, Italy
| | - Orazio Schillaci
- Department of Nuclear Medicine, Tor Vergata University of Rome, Rome, Italy
| | | | | | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100, Latina, Italy.
- Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy.
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Kang SH, Choi HI, Kim YH, Lee EY, Ahn JM, Han S, Lee PH, Roh JH, Yun SH, Park DW, Kang SJ, Lee SW, Lee CW, Moon DH, Park SW, Park SJ. Impact of Follow-Up Ischemia on Myocardial Perfusion Single-Photon Emission Computed Tomography in Patients with Coronary Artery Disease. Yonsei Med J 2017; 58:934-943. [PMID: 28792136 PMCID: PMC5552647 DOI: 10.3349/ymj.2017.58.5.934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 04/12/2017] [Accepted: 05/29/2017] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Few studies have reported on predicting prognosis using myocardial perfusion single-photon emission computed tomography (SPECT) during coronary artery disease (CAD) treatment. Therefore, we aimed to assess the clinical implications of myocardial perfusion SPECT during follow-up for CAD treatment. MATERIALS AND METHODS We enrolled 1153 patients who had abnormal results at index SPECT and underwent follow-up SPECT at intervals ≥6 months. Major adverse cardiac events (MACE) were compared in overall and 346 patient pairs after propensity-score (PS) matching. RESULTS Abnormal SPECT was associated with a significantly higher risk of MACE in comparison with normal SPECT over the median of 6.3 years (32.3% vs. 19.8%; unadjusted p<0.001). After PS matching, abnormal SPECT posed a higher risk of MACE [32.1% vs. 19.1%; adjusted hazard ratio (HR)=1.73; 95% confidence interval (CI)=1.27-2.34; p<0.001] than normal SPECT. After PS matching, the risk of MACE was still higher in patients with abnormal follow-up SPECT in the revascularization group (30.2% vs. 17.9%; adjusted HR=1.73; 95% CI=1.15-2.59; p=0.008). Low ejection fraction [odds ratio (OR)=5.33; 95% CI=3.39-8.37; p<0.001] and medical treatment (OR=2.68; 95% CI=1.93-3.72; p<0.001) were independent clinical predictors of having an abnormal result on follow-up SPECT. CONCLUSION Abnormal follow-up SPECT appears to be associated with a high risk of MACE during CAD treatment. Follow-up SPECT may play a potential role in identifying patients at high cardiovascular risk.
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Affiliation(s)
- Se Hun Kang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hyo In Choi
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Hak Kim
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Eun Young Lee
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Min Ahn
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seungbong Han
- Department of Applied Statistics, Gachon University, Seongnam, Korea
| | - Pil Hyung Lee
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Hyung Roh
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Han Yun
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Duk Woo Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Soo Jin Kang
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung Whan Lee
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Cheol Whan Lee
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae Hyuk Moon
- Department of Nuclear Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seong Wook Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Kennedy MW, Fabris E, Suryapranata H, Kedhi E. Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients? Cardiovasc Diabetol 2017; 16:51. [PMID: 28427383 PMCID: PMC5397766 DOI: 10.1186/s12933-017-0533-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/08/2017] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus (DM) is associated with an excess in cardiovascular morbidity and mortality, and is characterized by increased rates of coronary artery disease. Furthermore, once atherosclerosis is established, this is associated with an increased extent, complexity and a more rapid progression than seen in non-DM patients. Ischemia is the single most important predictor of future hard cardiac events and ischemia correction remains the cornerstone of current revascularization strategies. However recent data suggests that, in DM patients, coronary atherosclerosis despite the absence of ischemia, detected by either invasive or non-invasive methods, may not be associated with the same low risk of future cardiac events as seen in non-DM patients. This review seeks to examine the current evidence supporting an ischemia driven revascularization strategy, and to challenge the notion that ischemia is the only clinically relevant factor in the prediction of cardiovascular outcomes in all-comer DM patients. Specifically, we examine whether in DM patients certain characteristics beyond ischemia, such as microvascular disease, coronary atherosclerosis burden, progression and plaque composition, may need to be considered for a more refined risk stratification in these high-risk patients.
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Affiliation(s)
- Mark W Kennedy
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Enrico Fabris
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Harry Suryapranata
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.,Diagram CRO, Zwolle, The Netherlands
| | - Elvin Kedhi
- Isala Hartcentrum, Docter van Heesweg 2, Zwolle, The Netherlands.
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20
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Visualization of the improvement of myocardial perfusion after coronary intervention using motorized fractional flow reserve pullback curve. Cardiovasc Interv Ther 2016; 33:99-108. [PMID: 27943219 PMCID: PMC5880845 DOI: 10.1007/s12928-016-0448-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/07/2016] [Indexed: 01/10/2023]
Abstract
This study aimed to evaluate the feasibility and utility of using motorized pullback of the pressure guidewire to provide a graphic assessment and prediction of the benefits of coronary intervention. Fractional flow reserve (FFR) measurements were performed with motorized pullback imaging in 20 patients who underwent successful percutaneous coronary intervention (PCI) of the left anterior descending artery. Physiological lesion length (PLL) was calculated using frame counts to determine stent length. FFR area was calculated by integrating the FFR values recorded during pullback tracing (FFRarea). The percentage increase in FFR area (%FFRarea) was defined as the ratio of the difference between the pre- and post-intervention FFRarea to the total frame count. The average FFR values were enhanced following PCI, from 0.64 to 0.82, and the median value of the difference between pre- and post-interventional FFR values (D-FFR) and %FFRarea were 0.13 and 10.6%, respectively. The %FFRarea demonstrated a significant positive correlation with D-FFR (R2, 0.61; p < 0.01). PLL tended to be longer and the %FFRarea was smaller in lesions with a gradual pressure-drop pattern than those with an abrupt pressure-drop pattern (35.37 vs. 20.40 mm, p = 0.07; 5.78 vs. 16.21%, p < 0.05, respectively). Motorized pullback tracing was able to identify the extent and location of stenosis and help in appropriate stent implantation, in addition to visualizing and quantifying the improvement in FFR following PCI.
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21
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Cuocolo A, Taillefer R. Serial cardiac SPECT studies: Technical issues and clinical implications. J Nucl Cardiol 2016; 23:1454-1456. [PMID: 27796848 DOI: 10.1007/s12350-016-0703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/28/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Raymond Taillefer
- Department of Radiology, Radio-oncology and Nuclear Medicine, Université de Montréal, Montreal, Canada
- Department of Nuclear Medicine, l'Hôpital du Haut-Richelieu, Saint-Jean-sur-Richelieu, Canada
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22
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The reproducibility and prognostic value of serial measurements of heart rate response to regadenoson during myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2016; 43:1493-502. [PMID: 27079736 DOI: 10.1007/s00259-016-3380-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/24/2016] [Indexed: 01/06/2023]
Abstract
PURPOSE The heart rate response (HRR, percentage change from baseline) to regadenoson during myocardial perfusion imaging (MPI) can provide incremental prognostic value in patients with known or suspected coronary artery disease. Our purpose was to evaluate the variability and prognostic value of HRR on serial measurements. METHODS We studied 648 consecutive patients (61 ± 11 years, 48 % with diabetes) who underwent two regadenoson MPI studies (16 ± 9 months between studies). HRR <30 % was defined as abnormal. All-cause mortality was determined by chart review and verified using the US Social Security Death Master File. RESULTS HRR was well correlated between the two studies (intraclass correlation coefficient 0.72, 95 % CI 0.67 - 0.76) with no systematic bias (mean difference 0.88 %, p = 0.2) or proportional bias (p = 0.5) by Bland-Altman analysis in all patients and in those with normal MPI on both studies. Of the 308 patients (48 %) with normal baseline HRR (HRR-1), 33 % had developed a blunted HRR on the second MPI study (HRR-2). Older age, male gender, end-stage renal disease, and abnormal baseline left ventricular ejection fraction were independent predictors of a new-onset abnormal HRR. During a mean follow-up of 2.4 ± 1.2 years, 55 patients (8.5 %) died. Patients with a blunted HRR-1 had increased mortality risk irrespective of their HRR-2 (p = 0.9, log-rank test). Among patients with normal HRR-1, a blunted HRR-2 was an independent predictor of all-cause mortality beyond clinical and traditional MPI data (hazard ratio 2.83, 95 % CI 1.14 - 7.03). Finally, patients with a normal HRR-1 and HRR-2 had the lowest event rate, while those with any abnormal HRR had an increased risk of death (hazard ratio 2.5, 95 % CI 1.2 - 5.4). CONCLUSION There was good correlation in the HRR to regadenoson on serial measurements without systematic or proportional biases. Patients with consistently normal HRR had the best prognosis.
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Petretta M, Salvatore M, Cuocolo A. Immortality time and serial myocardial perfusion imaging: Only those who do not die may repeat the exam. J Nucl Cardiol 2016; 23:113-6. [PMID: 25971990 DOI: 10.1007/s12350-015-0171-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Mario Petretta
- Department of Translational Medical Sciences, University Federico II, Naples, Italy.
| | | | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy.
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El-Hajj S, AlJaroudi WA, Farag A, Bleich S, Manaoragada P, Iskandrian AE, Hage FG. Effect of changes in perfusion defect size during serial regadenoson myocardial perfusion imaging on cardiovascular outcomes in high-risk patients. J Nucl Cardiol 2016; 23:101-12. [PMID: 26017713 DOI: 10.1007/s12350-015-0174-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/30/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prognostic value of single-photon emission computed tomography myocardial perfusion imaging (MPI) is well established. There is a paucity of data on the prognostic value of changes in perfusion defect size (PDS) on serial MPIs. METHODS From the MPI database at the University of Alabama at Birmingham, consecutive patients who underwent two regadenoson stress MPIs between July 2008 and March 2013 were identified. The MPIs were analyzed side-by-side using an automated software program for presence and change in PDS. Improvement in PDS was defined as a reduction ≥5% of left ventricle. A drop in left ventricular ejection fraction (LVEF) was defined as a decrease ≥5%. The primary outcome was a composite of death, myocardial infarction (MI), and coronary revascularization (CR). RESULTS There were 698 patients (61 ± 11 years, 53% male, 48% diabetes, 25% prior MI, 49% prior CR) who underwent two regadenoson MPIs within 16 ± 9 months for clinical indications. The primary outcome occurred in 167 (24%) patients (8% death, 9% MI, 15% CR) during 24 ± 16 months of follow-up after the second MPI. The MPIs were normal in both studies in 399 (57%, Group 1), showed improvement in 94 (14%, Group 2, PDS 15% ± 16% vs 28% ± 18%, P < .001) and no change or worsening in 205 patients (29%, Group 3, 28% ± 17% vs 20% ± 17%, P < .001). The best outcomes were seen in Group 1 and the worst in Group 3 (log-rank P < .001). Similar trends were seen for the components of the primary outcome (P = .04 for death, P < .001 for MI, P < .001 for CR). In a Cox-regression model that adjusted for baseline factors including PDS and LVEF on initial MPI, the hazard ratios for primary outcome were 2.0 (P = .02) and 3.9 (P < .001) for Groups 2 and 3 compared to Group 1, respectively. In addition, an LVEF drop ≥5% was independently associated with the primary outcome (HR 1.5, P = .01). CONCLUSION Changes in PDS and LVEF on serial MPIs provide incremental prognostic information to initial and follow-up MPI findings. Lack of improvement or an increase in PDS and a drop in LVEF identify high-risk patients.
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Affiliation(s)
- Stephanie El-Hajj
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Wael A AlJaroudi
- Division of Cardiovascular Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ayman Farag
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Steven Bleich
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Padma Manaoragada
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Administration Medical Center, Birmingham, AL, USA.
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Gewirtz H. Functional Versus Anatomic Imaging of CAD: Lessons Learned from Recent Clinical Trials. Curr Cardiol Rep 2015; 18:4. [DOI: 10.1007/s11886-015-0686-5] [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] [Indexed: 11/29/2022]
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Mentz RJ, Fiuzat M, Shaw LK, Farzaneh-Far A, M O'Connor C, Borges-Neto S. Ischaemia change with revascularisation versus medical therapy in reduced ejection fraction. Open Heart 2015; 2:e000284. [PMID: 26339498 PMCID: PMC4555068 DOI: 10.1136/openhrt-2015-000284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/16/2015] [Accepted: 07/31/2015] [Indexed: 11/13/2022] Open
Abstract
Objective Nuclear imaging data demonstrate that revascularisation leads to favourable effects on ischaemia burden and improved outcomes compared with medical therapy (MT). In patients with heart failure (HF), the effects of MT versus revascularisation on ischaemia change and its independent prognostic significance requires investigation. Methods From the Duke Databank, we performed a retrospective analysis of 278 consecutive patients with coronary artery disease (CAD) and ejection fraction (EF) ≤40%, who underwent 2 serial myocardial perfusion scans between 1993 and 2009. Ischaemia change was calculated for patients undergoing MT alone, or revascularisation. Cox proportional hazards regression modelling was used to identify factors associated with death/myocardial infarction (MI). Results The magnitude of ischeamia reduction was greater with revascularisation than with MT alone (median change of −6% vs 0%, p<0.001). With revascularisation, more patients experienced ≥5% ischaemia reduction compared with MT (52% vs 25%, p<0.01) and a similar percentage experienced ≥5% ischaemia worsening (13% vs 18%, p=0.37). After risk adjustment, ≥5% ischaemia worsening was associated with decreased death/MI (HR=0.58; 95% CI 0.36 to 0.96). Conclusions In patients with HF with CAD, revascularisation improves long-term ischaemia burden compared with MT. Ischaemia worsening on nuclear imaging was associated with reduced risk of death/MI, potentially related to development of ischaemic viable myocardium as opposed to scar tissue.
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Affiliation(s)
- Robert J Mentz
- Division of Cardiology , Duke University Medical Center (DUMC) , Durham, North Carolina , USA
| | - Mona Fiuzat
- Division of Clinical Pharmacology , DUMC , Durham, North Carolina , USA
| | - Linda K Shaw
- Duke Clinical Research Institute , Durham, North Carolina , USA
| | - Afshin Farzaneh-Far
- Section of Cardiology , University of Illinois at Chicago , Chicago, Illinois, USA
| | - Christopher M O'Connor
- Division of Cardiology , Duke University Medical Center (DUMC) , Durham, North Carolina , USA
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Bagnall A, Spyridopoulos I. The evidence base for revascularisation of chronic total occlusions. Curr Cardiol Rev 2015; 10:88-98. [PMID: 24694105 PMCID: PMC4021288 DOI: 10.2174/1573403x10666140331125659] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 12/15/2013] [Accepted: 01/20/2014] [Indexed: 01/22/2023] Open
Abstract
When patients with ischaemic heart disease are considered for revascularisation the Heart Team's aim is to choose a therapy that will provide complete relief of angina for an acceptable procedural risk. Complete functional revascularisation of ischaemic myocardium is thus the goal and for this reason the presence of a chronic total occlusion (CTO) - which remain the most technically challenging lesions to revascularise percutaneously - is the most common reason for selecting coronary artery bypass surgery. From the behaviour of Heart Teams it is clear that physicians believe that CTOs are important. Yet when faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximal LAD) or too high risk, there remains a reluctance to undertake CTO PCI, despite significant recent advances in procedural success and safety and a considerable body of evidence supporting a survival benefit following successful CTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia and left ventricular dysfunction and further explores the evidence relating their treatment to improved quality of life and prognosis in patients with these features.
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Affiliation(s)
| | - Ioakim Spyridopoulos
- Department of Cardiology, The Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN. UK.
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Ko SM, Hwang HK, Kim SM, Cho IH. Multi-modality imaging for the assessment of myocardial perfusion with emphasis on stress perfusion CT and MR imaging. Int J Cardiovasc Imaging 2015; 31 Suppl 1:1-21. [PMID: 25809387 DOI: 10.1007/s10554-015-0645-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/16/2015] [Indexed: 01/29/2023]
Abstract
High-quality and non-invasive diagnostic tools for assessing myocardial ischemia are necessary for therapeutic decisions regarding coronary artery disease. Myocardial perfusion has been studied using myocardial contrast echo perfusion, single-photon emission computed tomography, positron emission tomography, cardiovascular magnetic resonance, and, more recently, computed tomography. The addition of coronary computed tomography angiography to myocardial perfusion imaging improves the specificity and overall diagnostic accuracy of detecting the hemodynamic significance of coronary artery stenosis. This study reviews the benefits, limitations, and imaging findings of various imaging modalities for assessing myocardial perfusion, with particular emphasis on stress perfusion computed tomography and cardiovascular magnetic resonance imaging.
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Affiliation(s)
- Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-ro, Hwayang-dong, Gwangjin-gu, Seoul, 143-729, Korea,
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Ruparelia N, Kharbanda RK. Role of coronary physiology in the contemporary management of coronary artery disease. World J Clin Cases 2015; 3:148-155. [PMID: 25685761 PMCID: PMC4317608 DOI: 10.12998/wjcc.v3.i2.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/19/2014] [Accepted: 10/29/2014] [Indexed: 02/05/2023] Open
Abstract
Coronary artery disease (CAD) remains the leading cause of death worldwide with approximately 1 in 30 patients with stable CAD experiencing death or acute myocardial infarction each year. The presence and extent of resultant myocardial ischaemia has been shown to confer an increased risk of adverse outcomes. Whilst, optimal medical therapy (OMT) forms the cornerstone of the management of patients with stable CAD, a significant number of patients present with ischaemia refractory to OMT. Historically coronary angiography alone has been used to determine coronary lesion severity in both stable and acute settings. It is increasingly clear that this approach fails to accurately identify the haemodynamic significance of lesions; especially those that are visually “intermediate” in severity. Revascularisation based upon angiographic appearances alone may not reduce coronary events above OMT. Technological advances have enabled the measurement of physiological indices including the fractional flow reserve, the index of microcirculatory resistance and the coronary flow reserve. The integration of these parameters into the routine management of patients presenting to the cardiac catheterization laboratory with CAD represents a critical adjunctive tool in the optimal management of these patients by identifying patients that would most benefit from revascularisation and importantly also highlighting patients that would not gain benefit and therefore reducing the likelihood of adverse outcomes associated with coronary revascularisation. Furthermore, these techniques are applicable to a broad range of patients including those with left main stem disease, proximal coronary disease, diabetes mellitus, previous percutaneous coronary intervention and with previous coronary artery bypass grafting. This review will discuss current concepts relevant to coronary physiology assessment, its role in the management of both stable and acute patients and future applications.
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Serial myocardial perfusion imaging: defining a significant change and targeting management decisions. JACC Cardiovasc Imaging 2015; 7:79-96. [PMID: 24433711 DOI: 10.1016/j.jcmg.2013.05.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 05/20/2013] [Accepted: 05/30/2013] [Indexed: 12/22/2022]
Abstract
Myocardial perfusion imaging (MPI) with gated single-photon emission tomography provides important information on the extent and severity of myocardial perfusion abnormalities, including myocardial ischemia. The availability of software for automated quantitative assessment of myocardial perfusion in an objective and more reproducible manner than visual assessment has allowed MPI to be particularly effective in serial evaluation. Serial testing using MPI is widely used in guiding patient care despite the lack of well-defined appropriateness use criteria. This should not be surprising because ischemic heart disease is a life-long malady subject to dynamic changes throughout its natural course and particularly following man-made interventions that may improve or worsen the disease process, such as medical therapy and coronary revascularization. Serial MPI has filled an important clinical gap by providing crucial information for managing patients with changes in clinical presentations or in anticipation of such changes in patients with stable symptoms. In the research arena, serial MPI has been widely applied in randomized controlled trials to study the impact of various medical and interventional therapies on myocardial perfusion, as well as the relative merits of new imaging procedures (hardware and/or software), radiotracers, and stressor agents. Serial testing, however, unlike initial or 1-time testing, has more stringent requirements and is subject to variability because of technical, procedural, interpretational, and biological factors. The intrinsic variability of MPI becomes important in interpreting serial tests in order to define a true change in a given patient and to guide clinical decision making. The purpose of this first comprehensive review on this subject is to illustrate where serial MPI may be useful clinically and in research studies, and to highlight strategies for addressing the various issues that are unique to serial testing in order to derive more valid and robust data from the serial scans.
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Clinical Cardiac Positron Emission Tomography. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nakazato R, Arsanjani R, Achenbach S, Gransar H, Cheng VY, Dunning A, Lin FY, Al-Mallah M, Budoff MJ, Callister TQ, Chang HJ, Cademartiri F, Chinnaiyan K, Chow BJW, Delago A, Hadamitzky M, Hausleiter J, Kaufmann P, Raff G, Shaw LJ, Villines T, Cury RC, Feuchtner G, Kim YJ, Leipsic J, Berman DS, Min JK. Age-related risk of major adverse cardiac event risk and coronary artery disease extent and severity by coronary CT angiography: results from 15 187 patients from the International Multisite CONFIRM Study. Eur Heart J Cardiovasc Imaging 2014; 15:586-94. [PMID: 24714312 DOI: 10.1093/ehjci/jet132] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS 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). METHODS AND RESULTS 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. CONCLUSION Among individuals without known CAD, non-obstructive, and obstructive CAD are associated with higher MACE rates, with different risk profiles based on age.
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Affiliation(s)
- Ryo Nakazato
- Department of Cardiology, St Luke's International Hospital, Tokyo, Japan
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Milvidaite I, Kulakiene I, Vencloviene J, Kinduris S, Jurkiene N, Grizas V, Navickas R, Slapikas R. Prognostic value of myocardial perfusion abnormalities for long-term prognosis in patients after coronary artery bypass grafting. Indian J Nucl Med 2014; 29:222-6. [PMID: 25400360 PMCID: PMC4228584 DOI: 10.4103/0972-3919.142623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
AIMS The objective was to evaluate the prognostic value of exercise myocardial perfusion scintigraphy (MPS) in patients who underwent coronary artery bypass grafting (CABG). SUBJECTS AND METHODS A retrospective, one-center study of 361 patients with multivessel coronary artery disease was carried out. All the patients underwent MPS after CABG due to worsened health status. MPS was performed at 4.5 years standard deviation (SD: 0.2), based on symptoms. MPS was carried out using Tc-99m methoxy isobutyl isonitrile and following a 1-day protocol (stress-rest). The end points were analyzed at 6.5 years (SD: 3.3) after MPS, on the average. STATISTICAL ANALYSIS USED SPSS software for Windows, version 13.0. The t-test or the χ(2)-test was used. Survival times were calculated. A multivariate Cox proportional hazards model was developed. RESULTS During the follow-up, death occurred in 54 patients, and 37 patients experienced major adverse cardiovascular events (MACE). In the multivariate analysis, advanced age hazard ratio (HR: 1.45; 95% confidence interval [CI]: 1.4-2.02; P = 0.027), previous myocardial infarction (HR: 3.17; 95% CI: 1.22-8.2; P = 0.018), left ventricular ejection fraction of <40% (HR: 2.16; 95% CI: 1.2-3.89; P = 0.01), and the summed stress score (SSS) of ≥4 (HR: 1.87; 95% CI: 1.02-3.41; P = 0.04) were independent predictors of all-cause death. The summed difference score (SDS) was the only independent predictor of MACE (HR: 1.26; 95% CI: 1.06-1.48; P = 0.034). CONCLUSIONS The parameters of MPS were found to have prognostic value in the long-term period after CABG. Advanced age, previous myocardial infarction, decreased left ventricular ejection fraction, and the abnormal SSS were associated with an increased risk of all-cause death. The SDS was found to be the only significant risk factor for MACE.
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Affiliation(s)
- Irena Milvidaite
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ilona Kulakiene
- Department of Nuclear Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jone Vencloviene
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Sarunas Kinduris
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Nemira Jurkiene
- Department of Nuclear Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytautas Grizas
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ramunas Navickas
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimvydas Slapikas
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Abstract
PURPOSE OF REVIEW Physiology-based evaluation in stable ischemic heart disease is transforming percutaneous cardiovascular intervention (PCI). Fractional flow reserve (FFR)-guided PCI is associated with more appropriate and beneficial outcomes at lower costs. The surgical community can no longer ignore this development. We review evidence for the rationale, practicality and appropriateness of FFR-guided coronary artery bypass grafting (CABG), as compared with the current conventional, anatomy-based strategy for surgical revascularization. RECENT FINDINGS Physiologic evaluation links the nature (anatomic or functional) of coronary stenoses to the perfused myocardium supplied by the target vessel and challenges the use of anatomy as the sole criterion for revascularization intervention. In CABG, a functional perfusion deficit/ischemia identifies myocardial territories that would physiologically benefit from revascularization by grafting beyond the functional stenosis. Conversely, deliberately not grafting beyond an anatomic stenosis would dramatically change the procedure of CABG. Recent studies of functionally guided revascularization (PCI or CABG) support this approach, while recent trials of PCI vs. CABG demonstrated a late survival advantage with anatomy-based CABG. Finally, new intraoperative imaging technologies are elucidating the physiologic consequences of surgical revascularization in real time, yielding insights into resolving this dilemma. SUMMARY Physiologic-based revascularization is challenging our thinking about the historic strategy for CABG. Understanding better the physiologic consequences of revascularization will drive the evolution of CABG in the future.
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Iwasaki K. Myocardial ischemia is a key factor in the management of stable coronary artery disease. World J Cardiol 2014; 6:130-9. [PMID: 24772253 PMCID: PMC3999333 DOI: 10.4330/wjc.v6.i4.130] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/16/2013] [Accepted: 03/03/2014] [Indexed: 02/07/2023] Open
Abstract
Previous studies demonstrated that coronary revascularization, especially percutaneous coronary intervention (PCI), does not significantly decrease the incidence of cardiac death or myocardial infarction in patients with stable coronary artery disease. Many studies using myocardial perfusion imaging (MPI) showed that, for patients with moderate to severe ischemia, revascularization is the preferred therapy for survival benefit, whereas for patients with no to mild ischemia, medical therapy is the main choice, and revascularization is associated with increased mortality. There is some evidence that revascularization in patients with no or mild ischemia is likely to result in worsened ischemia, which is associated with increased mortality. Studies using fractional flow reserve (FFR) demonstrate that ischemia-guided PCI is superior to angiography-guided PCI, and the presence of ischemia is the key to decision-making for PCI. Complementary use of noninvasive MPI and invasive FFR would be important to compensate for each method's limitations. Recent studies of appropriateness criteria showed that, although PCI in the acute setting and coronary bypass surgery are properly performed in most patients, PCI in the non-acute setting is often inappropriate, and stress testing to identify myocardial ischemia is performed in less than half of patients. Also, some studies suggested that revascularization in an inappropriate setting is not associated with improved prognosis. Taken together, the presence and the extent of myocardial ischemia is a key factor in the management of patients with stable coronary artery disease, and coronary revascularization in the absence of myocardial ischemia is associated with worsened prognosis.
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Affiliation(s)
- Kohichiro Iwasaki
- Kohichiro Iwasaki, Department of Cardiology, Okayama Kyokuto Hospital, Okayama 703-8265, Japan
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Puri R, Nicholls SJ, Ellis SG, Tuzcu EM, Kapadia SR. High-Risk Coronary Atheroma. J Am Coll Cardiol 2014; 63:1134-1140. [DOI: 10.1016/j.jacc.2013.05.088] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/10/2013] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
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A Review of JACC Journal Articles on the Topic of Interventional Cardiology: 2011–2012. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kereiakes DJ, Stone GW. In mildly symptomatic patients, should an invasive strategy with catheterization and revascularization be routinely undertaken?: in mildly symptomatic patients, an invasive strategy with catheterization and revascularization should be routinely undertaken. Circ Cardiovasc Interv 2013; 6:107-13; discussion 113. [PMID: 23424270 DOI: 10.1161/circinterventions.112.000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dean J Kereiakes
- The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, Ohio 45219, USA.
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Hage FG, Gupta A, Iskandrian AE. Risk assessment in the era of high-speed myocardial perfusion imaging. J Nucl Cardiol 2012; 19:1102-5. [PMID: 22996833 DOI: 10.1007/s12350-012-9625-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Velazquez EJ. Does imaging-guided selection of patients with ischemic heart failure for high risk revascularization improve identification of those with the highest clinical benefit?: Myocardial imaging should not exclude patients with ischemic heart failure from coronary revascularization. Circ Cardiovasc Imaging 2012; 5:271-9; discussion 279. [PMID: 22438425 DOI: 10.1161/circimaging.111.964650] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eric J Velazquez
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
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