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Skali H, Di Carli MF, Blankstein R, Chow BJ, Beanlands RS, Berman DS, Germano G, Min JK, Merhige M, Williams B, Veledar E, Shaw LJ, Dorbala S. Stress Myocardial Perfusion PET Provides Incremental Risk Prediction in Patients with and Patients without Diabetes. Radiol Cardiothorac Imaging 2019; 1:e180018. [PMID: 33778500 PMCID: PMC7970097 DOI: 10.1148/ryct.2019180018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/03/2019] [Accepted: 05/02/2019] [Indexed: 06/01/2023]
Abstract
PURPOSE To evaluate the prognostic value of myocardial perfusion PET in patients with and patients without diabetes mellitus. MATERIALS AND METHODS The authors performed a retrospective analysis of prospectively acquired data from a multicenter registry cohort of 7061 patients, including 1966 with diabetes mellitus, who underwent clinically indicated rest-stress rubidium 82 (82Rb) myocardial perfusion PET. The mean patient age (±standard deviation) was 63.3 years ± 13. Of the 7061 patients, 3348 were women (47.4%), 2296 (32.5%) had known coronary artery disease, and 1895 (26.8%) had previously undergone revascularization. The primary end point was cardiac death (n = 169) assessed at a mean of 2.5 years ± 1.5. The authors used Cox proportional hazards models and risk reclassification measures stratified according to diabetes status. RESULTS In multivariable models adjusting for established clinical predictors, increasing magnitude of stress myocardial perfusion abnormality was associated with greater risk of cardiac death in patients with diabetes (hazard ratio [HR]: 7.2; 95% confidence interval [CI]: 3.1, 16.8) for severely abnormal myocardium compared with normal myocardium. The addition of stress myocardial perfusion imaging results significantly improved the fit of a clinical model for predicting cardiac death in patients with and patients without diabetes. Myocardial perfusion PET improved risk reclassification for cardiac death in patients with diabetes (category-based net reclassification index: 0.39; 95% CI: 0.15, 0.60, P < .001). Among diabetic patients, an abnormal myocardial perfusion PET scan was associated with increased risk of cardiac death (HR: 4.4; 95% CI: 2.0, 9.7) in all important clinical subgroups based on age, sex, obesity, or prior revascularization. CONCLUSION In a large cohort of patients referred for clinical 82Rb stress PET, myocardial perfusion imaging results provided incremental risk prediction of cardiac death in patients with and patients without diabetes mellitus.© RSNA, 2019Supplemental material is available for this article.
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Kianoush S, Al Rifai M, Whelton SP, Shaya GE, Bush AL, Graham G, Wong ND, Blaha MJ. Stratifying cardiovascular risk in diabetes: The role of diabetes-related clinical characteristics and imaging. J Diabetes Complications 2016; 30:1408-15. [PMID: 27179751 DOI: 10.1016/j.jdiacomp.2016.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 02/07/2023]
Abstract
Diabetes is a major coronary heart disease (CHD) and cardiovascular disease (CVD) risk factor and has traditionally been classified as a CHD risk equivalent. CVD risk, however, is heterogeneous among diabetic patients and thus further evaluation is warranted before initiating or titrating preventive pharmacotherapy. Prognostic clinical characteristics of diabetes such as age of onset, duration, and severity of diabetes, as well as concomitant cardiometabolic factors account for much of the variability in CHD and CVD risk. This heterogeneity can also be evaluated directly using non-invasive imaging, which allows for a more individualized risk assessment in order to minimize both under and overtreatment. In this paper, we review guideline recommendations for atherosclerotic CVD risk assessment driving the use of statins or aspirin for certain subgroups of patients with diabetes. We further discuss imaging techniques, such as stress myocardial perfusion imaging, coronary computed tomography angiography, and coronary artery calcium (CAC) scoring that can guide the decision to treat high-risk patients. Among imaging tests, current guidelines consider CAC scoring the most appropriate risk stratification tool for asymptomatic individuals with diabetes that can guide initiating/intensifying or withholding the most aggressive pharmacological therapies among high-risk (CAC>100) or low-risk (CAC=0) individuals, respectively.
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Affiliation(s)
- Sina Kianoush
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | - Mahmoud Al Rifai
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | | | - Aaron L Bush
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | - Garth Graham
- Aetna Foundation, Hartford, CT, USA; University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Nathan D Wong
- Division of Cardiology, University of California, Irvine, Irvine, CA, USA.
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins, Baltimore, MD, USA.
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Rassi CHRE, Churchill TW, Tavares CAF, Fahel MG, Rassi FPO, Uchida AH, Wajchenberg BL, Lerario AC, Hulten E, Nasir K, Bittencourt MS, Rochitte CE, Blankstein R. Use of imaging and clinical data to screen for cardiovascular disease in asymptomatic diabetics. Cardiovasc Diabetol 2016; 15:28. [PMID: 26861208 PMCID: PMC4748642 DOI: 10.1186/s12933-016-0334-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 01/13/2016] [Indexed: 12/25/2022] Open
Abstract
Background There is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease. We sought to compare the yield of testing for pre-clinical atherosclerosis with various approaches. Methods 98 asymptomatic individuals with T2DM without known coronary artery disease (CAD) were enrolled in a prospective study and underwent carotid ultrasound, exercise treadmill testing (ETT), coronary artery calcium (CAC) scoring, and coronary computed tomography angiography (CTA). Results Of 98 subjects (average age 55 ± 6, 64 % female), 43 (44 %) had coronary plaque detectable on CTA, and 38 (39 %) had CAC score >0. By CTA, 16 (16 %) had coronary stenosis ≥50 %, including three subjects with CAC = 0. Subjects with coronary plaque had greater prevalence of carotid plaque (58 % vs. 38 %, p = 0.01) and greater carotid intima media thickness (0.80 ± 0.20 mm vs. 0.70 ± 0.11 mm, p = 0.02). Notably, 18 of 55 subjects (33 %) with normal CTA had carotid plaque. Eight subjects had a positive ETT, of whom five had ≥ 50 % coronary stenosis, two had <50 % stenosis, and one had no CAD. Among these tests, CAC scoring had the highest sensitivity and specificity for prediction of CAD. Conclusion Among asymptomatic subjects with T2DM, a majority (56 %) had no CAD by CTA. When compared to CTA, CAC was the most accurate screening modality for detection of CAD, while ETT and carotid ultrasound were less sensitive and specific. However, 33 % of subjects with normal coronary CTA had carotid plaque, suggesting that screening for carotid plaque might better characterize stroke risk in such patients.
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Affiliation(s)
- Carlos Henrique Reis Esselin Rassi
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Timothy W Churchill
- Department of Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Carlos A Fernandes Tavares
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Mateus Guimaraes Fahel
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Fabricia P O Rassi
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Augusto H Uchida
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Bernardo L Wajchenberg
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Antonio C Lerario
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Edward Hulten
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Khurram Nasir
- Department of Cardiology, Baptist Health South Florida, 8900 N. Kendall Drive, Miami, FL, 33176, USA.
| | - Márcio S Bittencourt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA. .,Center for Clinical and Epidemiological Research, Division of Internal Medicine, University Hospital, and State of São Paulo Cancer Institute (ICESP), University of São Paulo, São Paulo, Brazil.
| | - Carlos Eduardo Rochitte
- Heart Institute (InCor), University of São Paulo, Medical School, Brazil, Av. Dr. Enéas de Carvalho Aguiar, 44, Andar AB, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
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Zimarino M, Prati F, Marano R, Angeramo F, Pescetelli I, Gatto L, Marco V, Bruno I, De Caterina R. The value of imaging in subclinical coronary artery disease. Vascul Pharmacol 2016; 82:20-9. [PMID: 26851577 DOI: 10.1016/j.vph.2016.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/28/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
Although the treatment of acute coronary syndromes (ACS) has advanced considerably, the ability to detect, predict, and prevent complications of atherosclerotic plaques, considered the main cause of ACS, remains elusive. Several imaging tools have therefore been developed to characterize morphological determinants of plaque vulnerability, defined as the propensity or probability of plaques to complicate with coronary thrombosis, able to predict patients at risk. By utilizing both intravascular and noninvasive imaging tools, indeed prospective longitudinal studies have recently provided considerable knowledge, increasing our understanding of determinants of plaque formation, progression, and instabilization. In the present review we aim at 1) critically analyzing the incremental utility of imaging tools over currently available "traditional" methods of risk stratification; 2) documenting the capacity of such modalities to monitor atherosclerosis progression and regression according to lifestyle modifications and targeted therapy; and 3) evaluating the potential clinical relevance of advanced imaging, testing whether detection of such lesions may guide therapeutic decisions and changes in treatment strategy. The current understanding of modes of progression of atherosclerotic vascular disease and the appropriate use of available diagnostic tools may already now gauge the selection of patients to be enrolled in primary and secondary prevention studies. Appropriate trials should now, however, evaluate the cost-effectiveness of an aggressive search of vulnerable plaques, favoring implementation of such diagnostic tools in daily practice.
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Affiliation(s)
- Marco Zimarino
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy.
| | - Francesco Prati
- San Giovanni Addolorata Hospital, CLI-Foundation, Rome, Italy
| | - Riccardo Marano
- Department of Radiological Sciences, Institute of Radiology "A. Gemelli" University Polyclinic Foundation, Catholic University, Rome, Italy
| | - Francesca Angeramo
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Irene Pescetelli
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
| | - Laura Gatto
- San Giovanni Addolorata Hospital, CLI-Foundation, Rome, Italy
| | - Valeria Marco
- San Giovanni Addolorata Hospital, CLI-Foundation, Rome, Italy
| | - Isabella Bruno
- Institute of Nuclear Medicine, "A. Gemelli" University Polyclinic Foundation, Catholic University, Rome, Italy
| | - Raffaele De Caterina
- Institute of Cardiology and Center of Excellence on Aging, "G. d'Annunzio" University, Chieti, Italy
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State-of-the-Art Updates on Cardiac Computed Tomographic Angiography for Assessing Coronary Artery Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:398. [PMID: 26092612 DOI: 10.1007/s11936-015-0398-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OPINION STATEMENT Cardiac computed tomographic angiography (CCTA) is a noninvasive imaging modality that is increasingly useful for the evaluation of coronary artery disease (CAD). Over the past decade, CCTA has consistently demonstrated an excellent sensitivity for the detection and exclusion of coronary atherosclerosis in patients with stable or acute chest pain symptoms. Large prospective registries have repeatedly demonstrated the prognostic significance of the presence, extent, or absence of CAD by CCTA. In response to initial concerns, technical advances have permitted a dramatic reduction in patient radiation exposure with preserved image quality. For many patients, the radiation dose of CCTA is less than half of that with conventional myocardial perfusion imaging while providing significantly more anatomic information. Furthermore, CCTA's excellent spatial resolution is increasingly being used for noninvasive assessment of coronary plaque, including the detection of higher-risk vulnerable plaque and association between plaque characteristics and ischemia. Finally, new promising techniques that incorporate physiology with anatomy, such as CT-based fractional flow reserve (FFR-CT) and CT perfusion (CTP), are allowing for the noninvasive hemodynamic assessment of coronary stenoses and improvements in the specificity of CCTA findings. Such advances augur a coming transition when CCTA will be a first-line test for the detection, exclusion, and even management of CAD in many patients.
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