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Practical instructions for using drugs in CT and MR cardiac imaging.
Rovere, G, Meduri, A, Savino, G, Flammia, FC, Lo Piccolo, F, Carafa, MRP, Larici, AR, Natale, L, Merlino, B, Marano, R
La Radiologia medica. 2021;(3):356-364
Abstract
The progressive increase in numbers of noninvasive cardiac imaging examinations broadens the spectrum of knowledge radiologists are expected to acquire in the management of drugs during CT coronary angiography (CTCA) and cardiac MR (CMR) to improve image quality for optimal visualization and assessment of the coronary arteries and adequate MR functional analysis. Aim of this review is to provide an overview on different class of drugs (nitrate, beta-blockers, ivabradine, anxiolytic, adenosine, dobutamine, atropine, dipyridamole and regadenoson) that can be used in CTCA and CMR, illustrating their main indications, contraindications, efficacy, mechanism of action, metabolism, safety, side effects or complications, and providing advices in their use.
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2.
CT coronary angiography-guided cardiovascular risk screening in asymptomatic patients: is it time?
Graby, J, Khavandi, A, Thompson, D, Downie, P, Antoniades, C, Rodrigues, JCL
Clinical radiology. 2021;(11):801-811
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the UK, whilst millions live with various forms of the disease. Coronary artery disease constitutes a significant portion of this morbidity and mortality, and is the leading cause of premature death. Increasing focus is thus being placed on the optimisation of CVD prevention, where risk screening plays a key role. Indeed, the decline in age-adjusted cardiovascular mortality achieved up to now has been largely attributed to primary preventative therapies (e.g., statins) introduced earlier in the disease process. National initiatives exist to improve cardiovascular health at a population level, but in its current form, CVD screening at the individual level is predominantly undertaken using multivariate risk scores based on population-based data. These have multiple innate flaws, highlighted in this review. Non-invasive imaging plays a key role in the screening of other disease processes, helping to personalise the screening process. Although the coronary artery calcium score as a screening tool has a role in national and international guidance, whether a shift to screening with computed tomography coronary angiography (CTCA) is now appropriate is open for discussion. Image acquisition techniques continue to improve with reducing radiation exposure and an ever-expanding evidence-base for additional prognostic data offered by CTCA. This enables the potential identification of sub-clinical atherosclerosis, including with novel artificial intelligence techniques. This review aims to report current guidelines regarding cardiac CT imaging in the asymptomatic primary prevention setting, advances in various CT technologies and future opportunities for progress in this field.
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Society of Cardiovascular Computed Tomography / North American Society of Cardiovascular Imaging - Expert Consensus Document on Coronary CT Imaging of Atherosclerotic Plaque.
Shaw, LJ, Blankstein, R, Bax, JJ, Ferencik, M, Bittencourt, MS, Min, JK, Berman, DS, Leipsic, J, Villines, TC, Dey, D, et al
Journal of cardiovascular computed tomography. 2021;(2):93-109
Abstract
Coronary computed tomographic angiography (CCTA) provides a wealth of clinically meaningful information beyond anatomic stenosis alone, including the presence or absence of nonobstructive atherosclerosis and high-risk plaque features as precursors for incident coronary events. There is, however, no uniform agreement on how to identify and quantify these features or their use in evidence-based clinical decision-making. This statement from the Society of Cardiovascular Computed Tomography and North American Society of Cardiovascular Imaging addresses this gap and provides a comprehensive review of the available evidence on imaging of coronary atherosclerosis. In this statement, we provide standardized definitions for high-risk plaque (HRP) features and distill the evidence on the effectiveness of risk stratification into usable practice points. This statement outlines how this information should be communicated to referring physicians and patients by identifying critical elements to include in a structured CCTA report - the presence and severity of atherosclerotic plaque (descriptive statements, CAD-RADS™ categories), the segment involvement score, HRP features (e.g., low attenuation plaque, positive remodeling), and the coronary artery calcium score (when performed). Rigorous documentation of atherosclerosis on CCTA provides a vital opportunity to make recommendations for preventive care and to initiate and guide an effective care strategy for at-risk patients.
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4.
Cardiac-CT and cardiac-MR cost-effectiveness: a literature review.
Centonze, M, Steidler, S, Casagranda, G, Alfonsi, U, Spagnolli, F, Rozzanigo, U, Palumbo, D, Faletti, R, De Cobelli, F
La Radiologia medica. 2020;(11):1200-1207
Abstract
Cardiovascular diseases are still among the first causes of death worldwide with a huge impact on healthcare systems. Within these conditions, the correct diagnosis of coronary artery disease with the most appropriate imaging-based evaluations is of utmost importance. The sustainability of the healthcare systems, considering the high economic burden of modern cardiac imaging equipments, makes cost-effective analysis an important tool, currently used for weighing different costs and health outcomes, when policy makers have to allocate funds and to prioritize interventions, getting the most out of their financial resources. This review aims at evaluating cost-effective analysis in the more recent literature, focused on the role of Calcium Score, coronary computed tomography angiography and cardiac magnetic resonance.
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5.
Non-invasive imaging of high-risk coronary plaque: the role of computed tomography and positron emission tomography.
Bing, R, Loganath, K, Adamson, P, Newby, D, Moss, A
The British journal of radiology. 2020;(1113):20190740
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Abstract
Despite recent advances, cardiovascular disease remains the leading cause of death globally. As such, there is a need to optimise our current diagnostic and risk stratification pathways in order to better deliver individualised preventative therapies. Non-invasive imaging of coronary artery plaque can interrogate multiple aspects of coronary atherosclerotic disease, including plaque morphology, anatomy and flow. More recently, disease activity is being assessed to provide mechanistic insights into in vivo atherosclerosis biology. Molecular imaging using positron emission tomography is unique in this field, with the potential to identify specific biological processes using either bespoke or re-purposed radiotracers. This review provides an overview of non-invasive vulnerable plaque detection and molecular imaging of coronary atherosclerosis.
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6.
Case Report and Literature Review on Low-Osmolar, Non-Ionic Iodine-Based Contrast-Induced Encephalopathy.
Liu, MR, Jiang, H, Li, XL, Yang, P
Clinical interventions in aging. 2020;:2277-2289
Abstract
Contrast-induced encephalopathy (CIE) is a rare complication following percutaneous carotid and coronary interventions, and important diagnostic radiological signs include brain edema and cortical enhancement. In this report, we detail a case of probable CIE in an 84-year-old woman following a normal diagnostic coronary angiography (CAG) that involved 20 mL of the low-osmolar, non-ionic monomeric, iodine-based contrast agent iopromide (Ultravist 370). The patient was unconscious and presented with hemiparesis, hemianopia, recurrent seizures, and cardiac and respiratory arrest within minutes to hours following the procedure. Non-contrast computed tomography (CT) of the head showed increased subarachnoid density, cortical enhancement, and brain edema in the right hemisphere. Three days of rehydration, reduction in cranial pressure, and treatment with an anticonvulsant and dexamethasone resulted in a gradual recovery with no neurological deficits. This case highlights that severe neurotoxic symptoms may occur in response to low doses of low-osmolar, non-ionic, monomeric contrast agents. This finding is of importance to interventional cardiologists for diagnostic considerations and development of treatment plans.
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Machine Learning and Deep Neural Networks Applications in Computed Tomography for Coronary Artery Disease and Myocardial Perfusion.
Monti, CB, Codari, M, van Assen, M, De Cecco, CN, Vliegenthart, R
Journal of thoracic imaging. 2020;:S58-S65
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Abstract
During the latest years, artificial intelligence, and especially machine learning (ML), have experienced a growth in popularity due to their versatility and potential in solving complex problems. In fact, ML allows the efficient handling of big volumes of data, allowing to tackle issues that were unfeasible before, especially with deep learning, which utilizes multilayered neural networks. Cardiac computed tomography (CT) is also experiencing a rise in examination numbers, and ML might help handle the increasing derived information. Moreover, cardiac CT presents some fields wherein ML may be pivotal, such as coronary calcium scoring, CT angiography, and perfusion. In particular, the main applications of ML involve image preprocessing and postprocessing, and the development of risk assessment models based on imaging findings. Concerning image preprocessing, ML can help improve image quality by optimizing acquisition protocols or removing artifacts that may hinder image analysis and interpretation. ML in image postprocessing might help perform automatic segmentations and shorten examination processing times, also providing tools for tissue characterization, especially concerning plaques. The development of risk assessment models from ML using data from cardiac CT could aid in the stratification of patients who undergo cardiac CT in different risk classes and better tailor their treatment to individual conditions. While ML is a powerful tool with great potential, applications in the field of cardiac CT are still expanding, and not yet routinely available in clinical practice due to the need for extensive validation. Nevertheless, ML is expected to have a big impact on cardiac CT in the near future.
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Prognostic value of cardiac CT.
Seitun, S, Clemente, A, Maffei, E, Toia, P, La Grutta, L, Cademartiri, F
La Radiologia medica. 2020;(11):1135-1147
Abstract
In the past decades, coronary computed tomography angiography (CCTA) has become a powerful tool in the management of coronary artery disease. The diagnostic and prognostic value of CCTA has been extensively demonstrated in both large observational studies and clinical trials among stable chest pain patients. The quantification of coronary artery calcium score (CACS) is a well-established predictor of cardiovascular morbidity and mortality in asymptomatic subjects. Besides CACS, the main strength of CCTA is the accurate assessment of the individual total atherosclerotic plaque burden, which holds important prognostic information. In addition, CCTA, by providing detailed information on coronary plaque morphology and composition with identification of specific high-risk plaque features, may further improve the risk stratification beyond the assessment of coronary stenosis. The development of new CCTA applications, such as stress myocardial CT perfusion and computational fluids dynamic applied to standard CCTA to derive CT-based fractional flow reserve (FFR) values have shown promising results to guide revascularization, potentially improving clinical outcomes in stable chest pain patients. In this review, starting from the role of CACS and moving beyond coronary stenosis, we evaluate the existing evidence of the prognostic effectiveness of the CCTA strategy in real-world clinical practice.
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Coronary artery calcium: A technical argument for a new scoring method.
Willemink, MJ, van der Werf, NR, Nieman, K, Greuter, MJW, Koweek, LM, Fleischmann, D
Journal of cardiovascular computed tomography. 2019;(6):347-352
Abstract
Coronary artery calcium (CAC) is a strong predictor for future cardiovascular events. Traditionally CAC has been quantified using the Agatston score, which was developed in the late 1980s for electron beam tomography (EBT). While EBT has been completely replaced by modern multiple-detector row CT technology, the traditional CAC scoring method by Agatston remains in use, although the literature indicates suboptimal reproducibility and subjects being incorrectly classified. The traditional Agatston scoring method counteracts the technical advances of CT technology, and prevents the use of thinner sections, obtained at lower tube voltage and overall decreased radiation exposure that has become available to other CT applications. Moreover, recent studies have shown that not only the total amount of CAC, but also its density and distribution in the coronary arterial tree may be of prognostic value. Acquisition and reconstruction techniques thus need to be adapted for modern CT technology and optimized for CAC quantification. In this review we describe the technical limitations of the Agatston score followed by our suggestions for developing a new and more robust CAC quantification method.
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Effect of Alprostadil on the Prevention of Contrast-Induced Nephropathy: A Meta-Analysis of 36 Randomized Controlled Trials.
Xie, J, Jiang, M, Lin, Y, Deng, H, Li, L
Angiology. 2019;(7):594-612
Abstract
Contrast-induced nephropathy (CIN) is the third leading cause of acquired acute renal injury in hospitalized patients. Alprostadil plays a role in the maintenance and redistribution of intrarenal blood flow and the excretion of electrolytes and water. However, the effectiveness of alprostadil in preventing CIN remains controversial. Thirty-six articles with a total of 5495 patients were included in this study. Both groups (experimental group and control group) received standard hydration therapy. In the experimental group, patients received different doses of alprostadil. Serum creatinine (SCr), blood urea nitrogen (BUN), estimated glomerular filtration rate (eGFR), cystatin C, creatinine clearance rate (CCr), and β2-microglobulin (β2-MG) were measured at 24, 48, and 72 hours after contrast media injection. The incidence of CIN in the experimental group was significantly lower than that in the control group (6.56% vs 16.74%). The level of SCr, cystatin C, BUN, and β2-MG in the experimental group was lower than those in the control group; CCr and eGFR in the experimental group were higher than those in the control group. This study demonstrated that alprostadil may reduce the incidence of CIN in patients undergoing coronary angiogram and/or percutaneous coronary intervention.