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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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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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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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Coronary atherosclerosis imaging by CT to improve clinical outcomes.
Williams, MC, Newby, DE, Nicol, ED
Journal of cardiovascular computed tomography. 2019;(5):281-287
Abstract
Coronary artery disease remains an important cause of morbidity and mortality world-wide. Coronary Computed Tomography Angiography (CCTA) has excellent diagnostic accuracy and the identification and stratification of coronary artery disease is associated with improved prognosis in multiple studies. Recent randomized controlled trials have shown that in patients with stable coronary artery disease, CCTA is associated with improved diagnosis, changes in investigations, changes in medical treatment and appropriate selection for revascularization. Importantly this diagnostic approach reduces the long-term risk of fatal and non-fatal myocardial infarction. The identification of adverse plaques on CCTA is known to be associated with an increased risk of acute coronary syndrome, but does not appear to be predictive of long-term outcomes independent of coronary artery calcium burden. Future research will involve the assessment of outcomes after CCTA in patients with acute chest pain and asymptomatic patients. In addition, more advanced quantification of plaque subtypes, vascular inflammation and coronary flow dynamics may identify further patients at increased risk.
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Stable Coronary Artery Disease: Treatment.
Braun, MM, Stevens, WA, Barstow, CH
American family physician. 2018;(6):376-384
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Abstract
Stable coronary artery disease refers to a reversible supply/demand mismatch related to ischemia, a history of myocardial infarction, or the presence of plaque documented by catheterization or computed tomography angiography. Patients are considered stable if they are asymptomatic or their symptoms are controlled by medications or revascularization. Treatment involves risk factor management, antiplatelet therapy, and antianginal medications. Tobacco cessation, exercise, and weight loss are the most important lifestyle modifications. Treatment of comorbidities such as diabetes mellitus, hyperlipidemia, and hypertension should be optimized to reduce cardiovascular risk. All patients should be started on a statin unless contraindicated. No data support the routine use of monotherapy with nonstatin drugs such as bile acid sequestrants, niacin, ezetimibe, or fibrates. Studies of niacin and fibrates as adjunctive therapy found no improvement in patient outcomes. Aspirin is the mainstay of antiplatelet therapy; clopidogrel is an alternative. Antianginal medications should be added in a stepwise approach beginning with a beta blocker. Calcium channel blockers, nitrates, and ranolazine are used as adjunctive or second-line therapy when beta blockers are ineffective or contraindicated. Select patients may benefit from coronary revascularization with percutaneous coronary intervention or coronary artery bypass grafting.
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Merits of FDG PET/CT and Functional Molecular Imaging Over Anatomic Imaging With Echocardiography and CT Angiography for the Diagnosis of Cardiac Device Infections.
Chen, W, Sajadi, MM, Dilsizian, V
JACC. Cardiovascular imaging. 2018;(11):1679-1691
Abstract
The diagnosis of cardiac device infections, particularly device-related endocarditis, is challenging. Fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) is based on in vivo FDG targeting of the pre-existing inflammatory cells at an infectious site. Hence, it is able to identify cardiac device infection early, before the development of morphological damages from the infectious process. Transesophageal echocardiography (TEE) and electrocardiographically gated computed tomographic angiography (CTA) are currently the first-line imaging studies for device-related endocarditis, but their application to evaluate the extracardiac components or sources of primary infection and/or emboli is limited. Functional FDG PET/CT may have unique advantages over the anatomically based TEE and CT or CTA in the following settings: 1) diagnosing infection earlier than TEE and CTA, before morphological damage ensues; 2) identifying prosthetic endocarditis when findings on TEE and CTA are inconclusive; 3) evaluating infection in the extracardiac components of devices; 4) detecting unexpected source of the primary infection; and 5) discovering embolic consequences of endocarditis in the body. All of these findings may ultimately affect patient management. Although the nonspecific nature of FDG is a concern in differentiating infection from inflammation, accurate diagnosis of infection can be reasonably achieved on the basis of FDG distribution pattern and clinical history or by adding radiolabeled white blood cell scan to improve specificity. Recent publications support the judicious use of FDG PET/CT, particularly in patients with inconclusive or negative results on initial echocardiography and CT.
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Coronary Artery Calcium Scoring: Is It Time for a Change in Methodology?
Blaha, MJ, Mortensen, MB, Kianoush, S, Tota-Maharaj, R, Cainzos-Achirica, M
JACC. Cardiovascular imaging. 2017;(8):923-937
Abstract
Quantification of coronary artery calcium (CAC) has been shown to be reliable, reproducible, and predictive of cardiovascular risk. Formal CAC scoring was introduced in 1990, with early scoring algorithms notable for their simplicity and elegance. Yet, with little evidence available on how to best build a score, and without a conceptual model guiding score development, these scores were, to a large degree, arbitrary. In this review, we describe the traditional approaches for clinical CAC scoring, noting their strengths, weaknesses, and limitations. We then discuss a conceptual model for developing an improved CAC score, reviewing the evidence supporting approaches most likely to lead to meaningful score improvement (for example, accounting for CAC density and regional distribution). After discussing the potential implementation of an improved score in clinical practice, we follow with a discussion of the future of CAC scoring, asking the central question: do we really need a new CAC score?
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Nonobstructive Coronary Artery Disease by Coronary CT Angiography Improves Risk Stratification and Allocation of Statin Therapy.
Emami, H, Takx, RAP, Mayrhofer, T, Janjua, S, Park, J, Pursnani, A, Tawakol, A, Lu, MT, Ferencik, M, Hoffmann, U
JACC. Cardiovascular imaging. 2017;(9):1031-1038
Abstract
OBJECTIVES This study sought to determine prognostic value of nonobstructive coronary artery disease (CAD) for atherosclerotic cardiovascular disease (ASCVD) events and to determine whether incorporation of this information into the pooled cohort equation reclassifies recommendations for statin therapy as defined by the 2013 guidelines for cholesterol management of the American College of Cardiology and American Heart Association (ACC/AHA). BACKGROUND Detection of nonobstructive CAD by coronary computed tomography angiography may improve risk stratification and permit individualized and more appropriate allocation of statin therapy. METHODS This study determined the pooled hazard ratio of nonobstructive CAD for ASCVD events from published studies and incorporated this information into the ACC/AHA pooled cohort equation. The study calculated revised sex- and ethnicity-based 10-year ASCVD risk and determined boundaries corresponding to the original 7.5% risk for ASCVD events. It also assessed reclassification for statin eligibility by incorporating the results from meta-analysis to individual patients from a separate cohort. RESULTS This study included 2 studies (2,295 subjects; 66% male; prevalence of nonobstructive CAD, 47%; median follow-up, 49 months; 67 ASCVD events). The hazard ratio of nonobstructive CAD for ASCVD events was 3.2 (95% confidence interval: 1.5 to 6.7). Incorporation of this information into the pooled cohort equation resulted in reclassification toward statin eligibility in individuals with nonobstructive CAD, with an original ASCVD score of 3.0% and 5.9% or higher in African-American women and men and a score of 4.4% and 4.6% or higher in Caucasian women and men, respectively. The absence of nonobstructive CAD resulted in reclassification toward statin ineligibility if the original ASCVD score was as 10.0% and 17.9% or lower in African-American women and men and 13.7% and 14.3% or lower in Caucasian women and men, respectively. Reclassification is observed in 14% of patients. CONCLUSIONS Detection of nonobstructive CAD by coronary computed tomography angiography improves risk stratification and permits individualized and more appropriate allocation of statin therapy across sex and ethnicity groups.
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Meta-Analysis of Individual Patient Data of Sodium Bicarbonate and Sodium Chloride for All-Cause Mortality After Coronary Angiography.
Brown, JR, Pearlman, DM, Marshall, EJ, Alam, SS, MacKenzie, TA, Recio-Mayoral, A, Gomes, VO, Kim, B, Jensen, LO, Mueller, C, et al
The American journal of cardiology. 2016;(10):1473-1479
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Abstract
We sought to examine the relation between sodium bicarbonate prophylaxis for contrast-associated nephropathy (CAN) and mortality. We conducted an individual patient data meta-analysis from multiple randomized controlled trials. We obtained individual patient data sets for 7 of 10 eligible trials (2,292 of 2,764 participants). For the remaining 3 trials, time-to-event data were imputed based on follow-up periods described in their original reports. We included all trials that compared periprocedural intravenous sodium bicarbonate to periprocedural intravenous sodium chloride in patients undergoing coronary angiography or other intra-arterial interventions. Included trials were determined by consensus according to predefined eligibility criteria. The primary outcome was all-cause mortality hazard, defined as time from randomization to death. In 10 trials with a total of 2,764 participants, sodium bicarbonate was associated with lower mortality hazard than sodium chloride at 1 year (hazard ratio 0.61, 95% confidence interval [CI] 0.41 to 0.89, p = 0.011). Although periprocedural sodium bicarbonate was associated with a reduction in the incidence of CAN (relative risk 0.75, 95% CI 0.62 to 0.91, p = 0.003), there exists a statistically significant interaction between the effect on mortality and the occurrence of CAN (hazard ratio 5.65, 95% CI 3.58 to 8.92, p <0.001) for up to 1-year mortality. Periprocedural intravenous sodium bicarbonate seems to be associated with a reduction in long-term mortality in patients undergoing coronary angiography or other intra-arterial interventions.
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10.
Role of computed tomography screening for detection of coronary artery disease.
Han, D, Lee, JH, Hartaigh, BÓ, Min, JK
Clinical imaging. 2016;(2):307-10
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Abstract
Coronary artery disease (CAD) is a leading cause of morbidity and mortality in Western populations, and the prediction and prevention of CAD is an inherent challenge facing current health care societies. Computed tomography (CT) has emerged as a noninvasive imaging tool in the field of cardiovascular disease. Notably, CT scanning for detection of coronary artery calcium (CAC) has proven useful in predicting adverse cardiovascular outcomes as well as early identification of CAD. In asymptomatic persons undergoing screening for CAD, CAC is well established as a surrogate of CAD risk and has demonstrated incremental benefit over and above traditional risk prediction tools. In addition, a zero CAC score has shown to reflect a substantially lower risk of CAD and may therefore be considered an important marker of CAD protection. Irrespective of screening in the asymptomatic population, CAC scanning has also displayed a beneficial role in the symptomatic population, specifically as gatekeeper in guiding further treatment decision making. Further still, the combination of alternative CT screening strategies such as CT screening for lung cancer with CAC scanning may hold particular promise as an effective screening approach by lowering overall health costs as well as limiting radiation exposure.