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Manuca RD, Covic AM, Brinza C, Floria M, Statescu C, Covic A, Burlacu A. Updated Strategies in Non-Culprit Stenosis Management of Multivessel Coronary Disease-A Contemporary Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:263. [PMID: 38399550 PMCID: PMC10890538 DOI: 10.3390/medicina60020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
The prevalence of multivessel coronary artery disease (CAD) in acute coronary syndrome (ACS) patients underscores the need for optimal revascularization strategies. The ongoing debate surrounding percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), hybrid interventions, or medical-only management adds complexity to decision-making, particularly in specific angiographic scenarios. The article critically reviews existing literature, providing evidence-based perspectives on non-culprit lesion revascularization in ACS. Emphasis is placed on nuances such as the selection of revascularization methods, optimal timing for interventions, and the importance of achieving completeness in revascularization. The debate between culprit-only revascularization and complete revascularization is explored in detail, focusing on ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including patients with cardiogenic shock. Myocardial revascularization guidelines and recent clinical trials support complete revascularization strategies, either during the index primary PCI or within a short timeframe following the culprit lesion PCI (in both STEMI and NSTEMI). The article also addresses the complexities of decision-making in NSTEMI patients with multivessel CAD, advocating for immediate multivessel PCI unless complex coronary lesions require a staged revascularization approach. Finally, the article provided contemporary data on chronic total occlusion revascularization in ACS patients, highlighting the prognostic impact. In conclusion, the article addresses the evolving challenges of managing multivessel CAD in ACS patients, enhancing thoughtful integration into the clinical practice of recent data. We provided evidence-based, individualized approaches to optimize short- and long-term outcomes. The ongoing refinement of clinical and interventional strategies for non-culprit lesion management remains dynamic, necessitating careful consideration of patient characteristics, coronary stenosis complexity, and clinical context.
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Affiliation(s)
- Rares-Dumitru Manuca
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Alexandra Maria Covic
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Crischentian Brinza
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Mariana Floria
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
- Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Cristian Statescu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Adrian Covic
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
- Nephrology Clinic, Dialysis, and Renal Transplant Center, “C.I. Parhon” University Hospital, 700503 Iasi, Romania
| | - Alexandru Burlacu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
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Yu W, Yang L, Zhang F, Liu B, Shi Y, Wang J, Shao X, Chen Y, Yang X, Wang Y. Machine learning to predict hemodynamically significant CAD based on traditional risk factors, coronary artery calcium and epicardial fat volume. J Nucl Cardiol 2023; 30:2593-2606. [PMID: 37434084 DOI: 10.1007/s12350-023-03333-0] [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: 01/31/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023]
Abstract
We sought to establish an explainable machine learning (ML) model to screen for hemodynamically significant coronary artery disease (CAD) based on traditional risk factors, coronary artery calcium (CAC) and epicardial fat volume (EFV) measured from non-contrast CT scans. 184 symptomatic inpatients who underwent Single Photon Emission Computed Tomography/Myocardial Perfusion Imaging (SPECT/MPI) and Invasive Coronary Angiography (ICA) were enrolled. Clinical and imaging features (CAC and EFV) were collected. Hemodynamically significant CAD was defined when coronary stenosis severity ≥ 50% with a matched reversible perfusion defect in SPECT/MPI. Data was randomly split into a training cohort (70%) on which five-fold cross-validation was done and a test cohort (30%). The normalized training phase was preceded by the selection of features using recursive feature elimination (RFE). Three ML classifiers (LR, SVM, and XGBoost) were used to construct and choose the best predictive model for hemodynamically significant CAD. An explainable approach based on ML and the SHapley Additive exPlanations (SHAP) method was deployed to generate individual explanation of the model's decision. In the training cohort, hemodynamically significant CAD patients had significantly higher age, BMI and EFV, higher proportions of hypertension and CAC comparing with controls (P all < .05). In the test cohorts, hemodynamically significant CAD had significantly higher EFV and higher proportion of CAC. EFV, CAC, diabetes mellitus (DM), hypertension, and hyperlipidemia were the highest ranking features by RFE. XGBoost produced better performance (AUC of 0.88) compared with traditional LR model (AUC of 0.82) and SVM (AUC of 0.82) in the training cohort. Decision Curve Analysis (DCA) demonstrated that XGBoost model had the highest Net Benefit index. Validation of the model also yielded a favorable discriminatory ability with the AUC, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 0.89, 68.0%, 96.8%, 94.4%, 79.0% and 83.9% in the XGBoost model. A XGBoost model based on EFV, CAC, hypertension, DM and hyperlipidemia to assess hemodynamically significant CAD was constructed and validated, which showed favorable predictive value. ML combined with SHAP can offer a transparent explanation of personalized risk prediction, enabling physicians to gain an intuitive understanding of the impact of key features in the model.
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Affiliation(s)
- Wenji Yu
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Le Yang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Feifei Zhang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Bao Liu
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Yunmei Shi
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Jianfeng Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Xiaoliang Shao
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China
| | - Yongjun Chen
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xiaoyu Yang
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yuetao Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging, Soochow University, No.185, Juqian Street, Changzhou, 213003, Jiangsu, China.
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Zhang J, Zhao N, Xu B, Xie L, Yin W, An Y, Yan H, Yu Y, Lu B. Angiographic Lesion Morphology Provides Incremental Value to Generalize Quantitative Flow Ratio for Predicting Myocardial Ischemia. Front Cardiovasc Med 2022; 9:872498. [PMID: 35734275 PMCID: PMC9207314 DOI: 10.3389/fcvm.2022.872498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
AimThe quantitative flow ratio (QFR) is favorable for functional assessment of coronary artery stenosis without pressure wires and induction of hyperemia. The aim of this study was to explore whether angiographic lesion morphology provides incremental value to generalize QFR for predicting myocardial ischemia in unselected patients.MethodsThis study was a substudy to the CT-FFR CHINA trial, referring 345 participants from five centers with suspected coronary artery disease on coronary CT angiography for diagnostic invasive coronary angiography (ICA). Fractional flow reserve (FFR) was measured in all vessels with 30–90% diameter stenosis. QFR was calculated in 186 lesions from 159 participants in a blinded manner. In addition, parameters to characterize lesion features were recorded or measured, including left anterior descending arteries (LADs)-involved lesions, side branch located at stenotic lesion (BL), multiple lesions (ML), minimal lumen diameter (MLD), reference lumen diameter (RLD), percent diameter stenosis (%DS), lesion length (LL), and LL/MLD4. Logistic regression was used to construct two kinds of models by combining single or two lesion parameters with the QFR. The performances of these models were compared with that of QFR on a per-vessel level.ResultsA total of 148 participants (mean age: 59.5 years; 101 men) with 175 coronary arteries were included for final analysis. In total, 81 (46%) vessels were considered hemodynamically significant. QFR correctly classified 82.29% of the vessels using FFR with a cutoff of 0.80 as reference standard. The area under the receiver operating characteristic curve (AUC) of QFR was 0.86 with a sensitivity, specificity, positive predictive value, and negative predictive value of 80.25, 84.04, 81.25, and 83.16%, respectively. The combined models (QFR + LAD + MLD, QFR + LAD + %DS, QFR + BL + MLD, and QFR + BL + %DS) outperformed QFR with higher AUCs (0.91 vs. 0.86, P = 0.02; 0.91 vs. 0.86, P = 0.02; 0.91 vs. 0.86, P = 0.02; 0.90 vs. 0.86, P = 0.03, respectively). Compared with QFR, the sensitivity of the combined models (QFR + BL and QFR + MLD) was improved (91.36 vs. 80.25%, 91.36 vs. 80.25%, respectively, both P < 0.05) without compromised specificity or accuracy.ConclusionCombined with angiographic lesion parameters, QFR can be optimized for predicting myocardial ischemia in unselected patients.
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Affiliation(s)
- Jie Zhang
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Zhao
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Xie
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weihua Yin
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunqiang An
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hankun Yan
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yitong Yu
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Lu
- Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Bin Lu,
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Zhang JM, Han H, Tan RS, Chai P, Fam JM, Teo L, Chin CY, Ong CC, Low R, Chandola G, Leng S, Huang W, Allen JC, Baskaran L, Kassab GS, Low AFH, Chan MYY, Chan KH, Loh PH, Wong ASL, Tan SY, Chua T, Lim ST, Zhong L. Diagnostic Performance of Fractional Flow Reserve From CT Coronary Angiography With Analytical Method. Front Cardiovasc Med 2021; 8:739633. [PMID: 34746257 PMCID: PMC8564016 DOI: 10.3389/fcvm.2021.739633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/10/2021] [Indexed: 11/15/2022] Open
Abstract
The aim of this study was to evaluate a new analytical method for calculating non-invasive fractional flow reserve (FFRAM) to diagnose ischemic coronary lesions. Patients with suspected or known coronary artery disease (CAD) who underwent computed tomography coronary angiography (CTCA) and invasive coronary angiography (ICA) with FFR measurements from two sites were prospectively recruited. Obstructive CAD was defined as diameter stenosis (DS) ≥50% on CTCA or ICA. FFRAM was derived from CTCA images and anatomical features using analytical method and was compared with computational fluid dynamics (CFD)-based FFR (FFRB) and invasive ICA-based FFR. FFRAM, FFRB, and invasive FFR ≤ 0.80 defined ischemia. A total of 108 participants (mean age 60, range: 30–83 years, 75% men) with 169 stenosed coronary arteries were analyzed. The per-vessel accuracy, sensitivity, specificity, and positive predictive and negative predictive values were, respectively, 81, 75, 86, 81, and 82% for FFRAM and 87, 88, 86, 83, and 90% for FFRB. The area under the receiver operating characteristics curve for FFRAM (0.89 and 0.87) and FFRB (0.90 and 0.86) were higher than both CTCA- and ICA-derived DS (all p < 0.0001) on per-vessel and per-patient bases for discriminating ischemic lesions. The computational time for FFRAM was much shorter than FFRB (2.2 ± 0.9 min vs. 48 ± 36 min, excluding image acquisition and segmentation). FFRAM calculated from a novel and expeditious non-CFD approach possesses a comparable diagnostic performance to CFD-derived FFRB, with a significantly shorter computational time.
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Affiliation(s)
- Jun-Mei Zhang
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Huan Han
- National Heart Centre Singapore, Singapore, Singapore
| | - Ru-San Tan
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Ping Chai
- Department of Cardiology, National University Heart Centre, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Lynette Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | | | - Ching Ching Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Ris Low
- National Heart Centre Singapore, Singapore, Singapore
| | | | - Shuang Leng
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Weimin Huang
- Institute for Infocomm Research, Agency for Science, Technology and Research, Singapore, Singapore
| | | | - Lohendran Baskaran
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Ghassan S Kassab
- California Medical Innovations Institute, San Diego, CA, United States
| | - Adrian Fatt Hoe Low
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Koo Hui Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Poay Huan Loh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Aaron Sung Lung Wong
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Swee Yaw Tan
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Terrance Chua
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Soo Teik Lim
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Liang Zhong
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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AlJaroudi WA, Hage FG. Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2020: positron emission tomography, computed tomography, and magnetic resonance. J Nucl Cardiol 2021; 28:2100-2111. [PMID: 34105040 PMCID: PMC8186871 DOI: 10.1007/s12350-021-02685-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022]
Abstract
Although the year 2020 was different from other years in many respects, the Journal of Nuclear Cardiology published excellent articles pertaining to imaging in patients with cardiovascular disease due to the dedication of the investigators in our field all over the world. In this review, we will summarize a selection of these articles to provide a concise review of the main advancements that have recently occurred in the field and provide the reader with an opportunity to review a wide selection of articles. We will focus on publications dealing with positron emission tomography, computed tomography, and magnetic resonance and hope that you will find this review helpful.
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Affiliation(s)
- Wael A AlJaroudi
- Division of Cardiovascular Medicine, Augusta University, Augusta, GA, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 306, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
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