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Screening coronary angiography in patients with long-standing diabetes mellitus undergoing kidney transplant evaluation.
Puttarajappa, CM, Tevar, AD, Hariharan, S, Silver, SJ, Soman, P, Hendrick, S, Mour, G, Wu, CM
Clinical transplantation. 2019;(4):e13501
Abstract
BACKGROUND The utility of coronary angiography in patients with diabetes mellitus undergoing kidney transplant evaluation is unclear. Predictors of critical angiography lesions in these patients will aid in appropriate use of angiography. METHODS Single-center study of 80 patients with ≥15 years of diabetes mellitus who underwent a screening coronary angiography despite a negative cardiac stress test. Risk factors for needing coronary intervention (CI) (percutaneous or bypass grafting) were analyzed. RESULTS Eighteen patients (23%) had a ≥70% occlusion in one or more major coronary vessel(s), with right coronary artery being the most commonly involved (71%). Fifteen patients (19%) underwent coronary intervention: ten percutaneously and five with bypass surgery. Risk factors for needing CI were not being on statin (OR 3.54, P = 0.047) and history of stroke or peripheral vascular disease (PVD; OR 3.5, P = 0.034). A model that included statin use, stroke/PVD history, and glycosylated hemoglobin had a receiver operating characteristic curve area under the curve of 0.8 to predict CI. CONCLUSION Despite a negative stress test, the prevalence of critical coronary lesions was high among kidney transplant candidates with long-standing diabetes. Risk factors for needing coronary intervention were absence of statin use and a history of stroke or peripheral vascular disease.
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Optimized energy of spectral coronary CT angiography for coronary plaque detection and quantification.
Symons, R, Choi, Y, Cork, TE, Ahlman, MA, Mallek, M, Bluemke, DA, Sandfort, V
Journal of cardiovascular computed tomography. 2018;(2):108-114
Abstract
BACKGROUND To optimize spectral coronary computed tomography angiography (CTA) for quantification of coronary artery plaque components. MATERIALS AND METHODS Fifty-one subjects were prospectively enrolled (88.2% male) (NCT02740699). Dual energy coronary CTA was performed at 90/Sn150 kVp using a 3rd generation dual-source CT scanner (SOMATOM Force, Siemens Healthcare). Dual energy images were reconstructed with a) linear mixed blending of 90 and Sn150 kVp data, b) virtual monoenergetic algorithm from 40 to 150 keV (at 10- keV intervals), and c) noise-optimized virtual monoenergetic algorithm from 40 to 150 keV. Image noise, iodine signal-to-noise-ratio (SNR), and contrast-to-noise ratio (CNR) for calcified and non-calcified plaque were measured. Qualitative readings of image quality were performed. Semi-automated software (QAngioCT, Medis) was used to quantify coronary plaque. Linear mixed-models that account for within-subject correlation of plaques were used to compare the results. RESULTS 100-150 keV noise-optimized virtual monoenergetic images had lower image noise than linear mixed images (all P < 0.05). The highest iodine SNR was achieved in 40 keV noise-optimized virtual monoenergetic images (33.3 ± 0.6 vs 23.3 ± 0.7 for linear mixed images, P < 0.001). 40-70 keV noise-optimized virtual monoenergetic images and 70 keV virtual monoenergetic images had superior coronary plaque CNR versus linear mixed images (all P < 0.01) with a maximum improvement of 20.1% and 22.7% for calcified plaque and non-calcified plaque (38.8 ± 2.2 vs 32.3 ± 2.3 and 17.3 ± 1.3 vs 14.1 ± 1.4, respectively). Using 90/Sn150 kVp linear mixed images as a reference, the plaque quantity was similar for 70 keV noise-optimized virtual monoenergetic images whereas low keV images (e.g. 40 keV) yielded significantly higher coronary plaque volumes (all P < 0.001). CONCLUSION Spectral coronary CTA with low energy (40-70 keV) post-processing can improve the CNR of coronary plaque components. However, low energies (such as 40 keV) resulted in different absolute volumes of coronary plaque compared to "conventional" mixed 90/Sn150 kVp images.
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Early detection of cardiac allograft vasculopathy using highly automated 3-dimensional optical coherence tomography analysis.
Pazdernik, M, Chen, Z, Bedanova, H, Kautzner, J, Melenovsky, V, Karmazin, V, Malek, I, Tomasek, A, Ozabalova, E, Krejci, J, et al
The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2018;(8):992-1000
Abstract
BACKGROUND Optical coherence tomography (OCT)-based studies of cardiac allograft vasculopathy (CAV) published thus far have focused mainly on frame-based qualitative analysis of the vascular wall. Full capabilities of this inherently 3-dimensional (3D) imaging modality to quantify CAV have not been fully exploited. METHODS Coronary OCT imaging was performed at 1 month and 12 months after heart transplant (HTx) during routine surveillance cardiac catheterization. Both baseline and follow-up OCT examinations were analyzed using proprietary, highly automated 3D graph-based optimal segmentation software. Automatically identified borders were efficiently adjudicated using our "just-enough-interaction" graph-based segmentation approach that allows to efficiently correct local and regional segmentation errors without slice-by-slice retracing of borders. RESULTS A total of 50 patients with paired baseline and follow-up OCT studies were included. After registration of baseline and follow-up pullbacks, a total of 356 ± 89 frames were analyzed per patient. During the first post-transplant year, significant reduction in the mean luminal area (p = 0.028) and progression in mean intimal thickness (p = 0.001) were observed. Proximal parts of imaged coronary arteries were affected more than distal parts (p < 0.001). High levels of LDL cholesterol (p = 0.02) and total cholesterol (p = 0.031) in the first month after HTx were the main factors associated with early CAV development. CONCLUSIONS Our novel, highly automated 3D OCT image analysis method for analyzing intimal and medial thickness in HTx recipients provides fast, accurate, and highly detailed quantitative data on early CAV changes, which are characterized by significant luminal reduction and intimal thickness progression as early as within the first 12 months after HTx.
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Association between diet quality and measures of body adiposity using the Rate Your Plate survey in patients presenting for coronary angiography.
Ganguzza, L, Ngai, C, Flink, L, Woolf, K, Guo, Y, Gianos, E, Burdowski, J, Slater, J, Acosta, V, Shephard, T, et al
Clinical cardiology. 2018;(1):126-130
Abstract
BACKGROUND Diet is a modifiable risk factor for cardiovascular disease; however, dietary patterns are historically difficult to capture in the clinical setting. Healthcare providers need assessment tools that can quickly summarize dietary patterns. Research should evaluate the effectiveness of these tools, such as Rate Your Plate (RYP), in the clinical setting. HYPOTHESIS RYP diet quality scores are associated with measures of body adiposity in patients referred for coronary angiography. METHODS Patients without a history of coronary revascularization (n = 400) were prospectively approached at a tertiary medical center in New York City prior to coronary angiography. Height, weight, and waist circumference (WC) were measured; body mass index (BMI) and waist-to-height ratio (WHtR) were calculated. Participants completed a 24-question RYP diet survey. An overall score was computed, and participants were divided into high (≥58) and low (≤57) diet quality groups. RESULTS Participants in the high diet quality group (n = 98) had significantly lower measures of body adiposity than did those in the low diet quality group (n = 302): BMI (P < 0.001), WC (P = 0.001), WHtR (P = 0.001). There were small but significant inverse correlations between diet score and BMI, WC, and WHtR (P < 0.001). These associations remained significant after adjustment for demographics, tobacco use, and socioeconomic factors. CONCLUSIONS Higher diet quality scores are associated with lower measures of body adiposity. RYP is a potential instrument to capture diet quality in a high-volume clinical setting. Further research should evaluate the utility of RYP in cardiovascular risk-factor control.
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Quality-of-Life and Economic Outcomes of Assessing Fractional Flow Reserve With Computed Tomography Angiography: PLATFORM.
Hlatky, MA, De Bruyne, B, Pontone, G, Patel, MR, Norgaard, BL, Byrne, RA, Curzen, N, Purcell, I, Gutberlet, M, Rioufol, G, et al
Journal of the American College of Cardiology. 2015;(21):2315-2323
Abstract
BACKGROUND Fractional flow reserve estimated using computed tomography (FFRCT) might improve evaluation of patients with chest pain. OBJECTIVES The authors sought to determine the effect on cost and quality of life (QOL) of using FFRCT instead of usual care to evaluate stable patients with symptoms suspicious for coronary disease. METHODS Symptomatic patients without known coronary disease were enrolled into 2 strata based on whether invasive or noninvasive diagnostic testing was planned. In each stratum, consecutive observational cohorts were evaluated with either usual care or FFRCT. The number of diagnostic tests, invasive procedures, hospitalizations, and medications during 90-day follow-up were multiplied by U.S. cost weights and summed to derive total medical costs. Changes in QOL from baseline to 90 days were assessed using the Seattle Angina Questionnaire, the EuroQOL, and a visual analog scale. RESULTS In the 584 patients, 74% had atypical angina, and the pre-test probability of coronary disease was 49%. In the planned invasive stratum, mean costs were 32% lower among the FFRCT patients than among the usual care patients ($7,343 vs. $10,734 p < 0.0001). In the noninvasive stratum, mean costs were not significantly different between the FFRCT patients and the usual care patients ($2,679 vs. $2,137; p = 0.26). In a sensitivity analysis, when the cost weight of FFRCT was set to 7 times that of computed tomography angiography, the FFRCT group still had lower costs than the usual care group in the invasive testing stratum ($8,619 vs. $ 10,734; p < 0.0001), whereas in the noninvasive testing stratum, when the cost weight of FFRCT was set to one-half that of computed tomography angiography, the FFRCT group had higher costs than the usual care group ($2,766 vs. $2,137; p = 0.02). Each QOL score improved in the overall study population (p < 0.0001). In the noninvasive stratum, QOL scores improved more in FFRCT patients than in usual care patients: Seattle Angina Questionnaire 19.5 versus 11.4, p = 0.003; EuroQOL 0.08 versus 0.03, p = 0.002; and visual analog scale 4.1 versus 2.3, p = 0.82. In the invasive cohort, the improvements in QOL were similar in the FFRCT and usual care patients. CONCLUSIONS An evaluation strategy based on FFRCT was associated with less resource use and lower costs within 90 days than evaluation with invasive coronary angiography. Evaluation with FFRCT was associated with greater improvement in quality of life than evaluation with usual noninvasive testing. (Prospective Longitudinal Trial of FFRCT Outcomes and Resource Impacts [PLATFORM]; NCT01943903).
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Diagnostic accuracy of coronary artery calcium for obstructive disease: results from the ACCURACY trial.
Budoff, MJ, Jollis, JG, Dowe, D, Min, J, ,
International journal of cardiology. 2013;(2):505-8
Abstract
BACKGROUND Although numerous trials have demonstrated the diagnostic accuracy of coronary artery calcium (CAC) scanning for prediction of obstructive disease, virtually all studies have been performed using Electron Beam CT (EBCT). We evaluated the diagnostic accuracy of CAC by 64-row CT to detect obstructive coronary stenosis compared to quantitative coronary angiography (QCA) in the ACCURACY multicenter trial. METHODS 16 sites prospectively enrolled 230 patients (pts) [59.5% males, 57yrs] with chest pain referred for invasive coronary angiography (ICA). Pts underwent CAC scan and CT angiography prior to ICA. Total CAC scores were correlated with angiographically documented stenoses using common cutpoints of CAC >0, >100 and >400. Significant obstructive disease was defined as >50% luminal stenosis by QCA. RESULTS The per-patient accuracy of CAC by 64-row CT compared to QCA demonstrates a high sensitivity and low specificity for the presence of obstructive disease (>50% stenosis on QCA). With CAC >0, >100 and >400, the sensitivities to predict stenosis were 98%, 88%, and 60%, whereas the specificities were 42%, 71%, and 88%, respectively. CONCLUSIONS Most previous CAC studies have focused on the fact that significant calcium places patients into a higher risk group in terms of future events, and should lead to more aggressive treatment with preventative therapies. This prospective multicenter results comparing 64-row CAC to QCA demonstrate that CAC using 64-row CT scanner, similar to previously published reports using EBCT, is highly sensitive and moderately specific test to predict significant coronary artery stenosis. The presence of abnormal levels of calcium may place patients into a higher risk group in terms of future events, and lead to more aggressive treatment with preventative therapies. However, the detection of calcium does not always help with a clinical diagnosis particularly in the presence of diffuse moderate coronary atheroma. Whether this information is complementary to CTA data remains to be validated.
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3D left ventricular extracellular volume fraction by low-radiation dose cardiac CT: assessment of interstitial myocardial fibrosis.
Nacif, MS, Liu, Y, Yao, J, Liu, S, Sibley, CT, Summers, RM, Bluemke, DA
Journal of cardiovascular computed tomography. 2013;(1):51-7
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Abstract
BACKGROUND Myocardial fibrosis leads to impaired cardiac function and events. Extracellular volume fraction (ECV) assessed with an iodinated contrast agent and measured by cardiac CT may be a useful noninvasive marker of fibrosis. OBJECTIVE The purpose of this study was to develop and evaluate a 3-dimensional (3D) ECV calculation toolkit (ECVTK) for ECV determination by cardiac CT. METHODS Twenty-four subjects (10 systolic heart failure, age, 60 ± 17 years; 5 diastolic failure, age 56 ± 20 years; 9 matched healthy subjects, age 59 ± 7 years) were evaluated. Cardiac CT examinations were done on a 320-multidetector CT scanner before and after 130 mL of iopamidol (Isovue-370; Bracco Diagnostics, Plainsboro, NJ, USA) was administered. A calcium score type sequence was performed before and 7 minutes after contrast with single gantry rotation during 1 breath hold and single cardiac phase acquisition. ECV was calculated as (ΔHUmyocardium/ΔHUblood) × (1 - Hct) where Hct is the hematocrit, and ΔHU is the change in Hounsfield unit attenuation = HUafter iodine - HUbefore iodine. Cardiac magnetic resonance imaging was performed to assess myocardial structure and function. RESULTS Mean 3D ECV values were significantly higher in the subjects with systolic heart failure than in healthy subjects and subjects with diastolic heart failure (mean, 41% ± 6%, 33% ± 2%, and 35% ± 5%, respectively; P = 0.02). Interobserver and intraobserver agreements were excellent for myocardial, blood pool, and ECV (intraclass correlation coefficient, >0.90 for all). Higher 3D ECV by cardiac CT was associated with reduced systolic circumferential strain, greater end-diastolic and -systolic volumes, and lower ejection fraction (r = 0.70, r = 0.60, r = 0.73, and r = -0.68, respectively; all P < 0.001). CONCLUSION 3D ECV by cardiac CT can be performed with ECVTK. We demonstrated increased ECV in subjects with systolic heart failure compared with healthy subjects. Cardiac CT results also showed good correlation with important functional heart biomarkers, suggesting the potential for myocardial tissue characterization with the use of 3D ECV by cardiac CT. This trial is registered at www.ClinicalTrials.gov as NCT01160471.
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Coronary artery diameter related to calcium scores and coronary risk factors as measured with multidetector computed tomography: a substudy of the ACCURACY trial.
Hamirani, YS, Nasir, K, Avanes, E, Kadakia, J, Budoff, MJ
Texas Heart Institute journal. 2013;(3):261-7
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Abstract
Arterial remodeling, an early change of atherosclerosis, can cause dilated arterial diameter. We measured coronary artery diameter with use of noncontrast 64-slice multidetector computed tomography (MDCT), and studied its association with coronary artery calcium levels and traditional coronary risk factors. We included 140 patients from the ACCURACY trial whose noncontrast MDCT images showed measurable coronary arteries. Using 3 measurements of left main coronary artery (LMCA) and right coronary artery (RCA) diameters within 3 mm of the ostium, we associated the results with traditional coronary risk factors and calcium scores. The prevalence of LMCA and RCA calcium was 22% and 51%, respectively. Mean arterial diameters were 5.67±1.18 mm (LMCA) and 4.66±1.08 mm (RCA). Correlations for LMCA and RCA diameters in 50 randomly chosen patients were 0.91 and 0.93 (interobserver) and 0.98 and 0.93 (intraobserver). Adjusted odds ratios for the relationship of LMCA and RCA diameters to calcium in male versus female patients were 5.65 (95% confidence interval [CI], 2.78-11.5) and 4.35 (95% CI, 2.24-8.47), respectively. Adjusted ratios and 95% CIs for the association of larger RCA diameter with age, hypertension, and body mass index were 1.36 (1.00-1.86), 3.13 (1.26-7.78), and 1.60 (1.16-2.22), respectively. Arterial diameters were larger in women and patients with higher calcium levels, and body mass index and hypertension were predictors of larger RCA diameters. These findings suggest a link between arterial remodeling and the severity of atherosclerosis.
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Coronary computer tomographic angiography for preoperative risk stratification in patients undergoing liver transplantation.
Jodocy, D, Abbrederis, S, Graziadei, IW, Vogel, W, Pachinger, O, Feuchtner, GM, Jaschke, W, Friedrich, G
European journal of radiology. 2012;(9):2260-4
Abstract
The assessment of the cardiovascular risk profile in patients with end-stage liver disease is essential prior to liver transplantation (LT) as cardiovascular diseases are major causes of morbidity and mortality in the posttransplant course. The aim of this study was to evaluate the accuracy of a 64-slice coronary computed tomographic angiography (CTA) and coronary calcium scoring (CCS) to predict the postoperative cardiovascular risk of patients assessed for LT. In this single center, observational study we included 54 consecutive patients who were assessed for LT and consequently transplanted. Twenty-four patients (44%) presented with a high CCS above 300 and/or a significant stenosis (>50% percent narrowing due to stenotic plaques) and were further referred to coronary angiography. Three of these patients had a more than 70% LAD stenosis with subsequent angioplasty (n=1) or conservative therapy (n=2). The other patients showed only diffuse CAD without significant stenosis. The remaining 30 patients with normal CTA findings were listed for LT without further tests. None of the 54 patients developed cardiovascular events peri- and postoperatively. This study indicated that CTA combined with CCS is a useful non-invasive imaging technique for pre-LT assessment of coronary artery disease and safe tool in the risk assessment of peri- and postoperative cardiovascular events in patients undergoing LT.
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The impact of plaque characterization assessed by intravascular ultrasound on myocardial perfusion after primary angioplasty in patients With ST-segment elevation myocardial infarction.
Nakata, T, Fujii, K, Fukunaga, M, Kawasaki, D, Kawabata-Lee, M, Masutani, M, Ohyanagi, M, Masuyama, T
Circulation journal : official journal of the Japanese Circulation Society. 2011;(11):2642-7
Abstract
BACKGROUND Previous studies described that inadequate tissue perfusion after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is associated with adverse cardiac events. This study evaluated whether plaque morphological intravascular ultrasound (IVUS) characteristics affects tissue perfusion after stent implantation in STEMI patients. METHODS AND RESULTS A total of consecutive 306 STEMI patients who underwent primary angioplasty with IVUS were analyzed. Maximum ST-segment elevation before angioplasty was compared with ST-segment levels 60min after angioplasty. Percent ST-segment resolution (STR) was calculated and categorized as complete (>70%), partial (30-70%), and absent (<30%). Qualitative and quantitative IVUS analyses were performed using standard methods. Plaque with ultrasound attenuation was defined as IVUS finding with backward signal attenuation behind plaque >180° without dense calcium. One-hundred-fifty patients had complete, 101 had partial, and 55 had absent STR. The incidence of in-hospital death tended to be higher in absent STR than in partial and complete STR groups. Multivariate analysis indicated that remodeling index (P=0.004), the presence of ultrasound attenuation (P=0.02), percentage stent expansion (P=0.03), and the presence of deep calcium (P=0.049) were the independent predictors related to the occurrence of absent STR after angioplasty. CONCLUSIONS Positive vessel remodeling, plaque with ultrasound attenuation >180°, deep calcium, and stent overexpansion as assessed by IVUS are associated with the absence of STR after primary angioplasty in patients with STEMI.