1
|
Lee E, Amadi C, Williams MC, Agarwal PP. Coronary Artery Disease: Role of Computed Tomography and Recent Advances. Radiol Clin North Am 2024; 62:385-398. [PMID: 38553176 DOI: 10.1016/j.rcl.2023.12.017] [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] [Indexed: 04/02/2024]
Abstract
In this review, the authors summarize the role of coronary computed tomography angiography and coronary artery calcium scoring in different clinical presentations of chest pain and preventative care and discuss future directions and new technologies such as pericoronary fat inflammation and the growing footprint of artificial intelligence in cardiovascular medicine.
Collapse
Affiliation(s)
- Elizabeth Lee
- Department of Radiology, Michigan Medicine, 1500 East Medical Center Drive, TC B1-148, Ann Arbor, MI 48109-5030, USA.
| | - Chiemezie Amadi
- Department of Radiology, Michigan Medicine, 1500 Medical Center Drive, Room 5481, Ann Arbor, MI 48109-5868, USA
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, The Queen's Medical Research Institute, Edinburg BioQuarter, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Prachi P Agarwal
- Department of Radiology, Division of Cardiothoracic Radiology, Michigan Medicine, 1500 East Medical Center Drive SPC 5868, Ann Arbor, MI 48109, USA
| |
Collapse
|
2
|
Jehangir M, Hippe DS, Huang G, Robinson JD. Limited Axial Interpretation of Coronary CT Angiography in the Emergency Department Setting. J Am Coll Radiol 2024; 21:591-600. [PMID: 37201689 DOI: 10.1016/j.jacr.2023.04.005] [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: 12/04/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Incorporating coronary CT angiographic (CCTA) imaging into emergency department (ED) workflows has been limited by the need for 24/7 real-time postprocessing. The aim of this study was to determine whether interpretation of transaxial CCTA images alone (limited axial interpretation [LI]) is noninferior to interpretation of combined transaxial and multiplanar reformation images (full interpretation [FI]) in assessing patients with acute chest pain in the ED. METHODS CCTA examinations from 74 patients were evaluated by two radiologists, one without dedicated CCTA training and one with basic CCTA experience. Each examination was evaluated three times in separate sessions, once by LI and twice by FI, in random order. Nineteen coronary artery segments were rated as having significant stenoses (≥50%) or not. Interreader agreement was assessed using Cohen's κ statistic. The primary analysis was whether the accuracy of LI for detecting significant stenosis was noninferior to that of FI at the patient level (margin = -10%). Secondary analyses included similar analyses of sensitivity and specificity, at both the patient and vessel levels. RESULTS Interreader agreement for significant stenosis was good for both LI and FI (κ = 0.72 vs 0.70, P = .74). Average accuracy for significant stenosis at the patient level was 90.5% for LI and 91.9% for FI, with a difference of -1.4%. The accuracy of LI was noninferior to FI, because the confidence interval did not include the noninferiority margin. Noninferiority was also found for patient-level sensitivity and for accuracy, sensitivity, and specificity at the vessel level. CONCLUSIONS LI of the coronary arteries using transaxial CCTA images may be sufficient for the detection of significant coronary artery disease in the ED setting.
Collapse
Affiliation(s)
- Maham Jehangir
- Department or Radiology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Gary Huang
- Department of Cardiology, University of Washington, Seattle, Washington
| | | |
Collapse
|
3
|
Dani A, Shah P, Desai D. Noninvasive imaging modalities in coronary artery disease: a meta analysis comparing coronary computed tomography angiography and standard of care. Future Cardiol 2024; 20:81-88. [PMID: 38275185 DOI: 10.2217/fca-2023-0103] [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: 08/10/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction: Coronary artery disease has become a global pandemic and a major cause of death. The risk-factor calculation for coronary artery damage is an invasive procedure. Aim: To compare coronary computed tomography angiography (CCTA) with standard of care (SOC) to calculate need for revascularization, invasive coronary angiography as well as for myocardial infarction (MI) incidence and all-cause mortality. Methodology, results & conclusion: CCTA is significantly correlated with a reduction in MI episodes (RR = 0.752, 95% CI = 0.578-1.409; p < 0.033) and an increase in revascularizations (RR = 1.401, 95% CI = 1.315-1.492; p < 0.001) and invasive coronary angiography procedures (RR = 1.304, 95% CI = 1.208-1.409; p < 0.001). However, it was found that it did not affect all-cause mortality. On the contrary, standard care approaches were associated with greater rates of MI but lesser referrals for invasive coronary angiography and revascularization.
Collapse
Affiliation(s)
- Avichal Dani
- Shri Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad 380006, India
| | - Pari Shah
- Shri Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad 380006, India
| | - Dev Desai
- Shri Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad 380006, India
| |
Collapse
|
4
|
Lan NSR, Thomas DR, Jones CL, Raju V, Soon J, Otto J, Wood C, Briffa T, Dwivedi G, Rankin JM, Ihdayhid AR. Evaluation of stable chest pain following emergency department presentation: Impact of first-line cardiac computed tomography diagnostic strategy in an Australian setting. Emerg Med Australas 2024; 36:31-38. [PMID: 37593996 DOI: 10.1111/1742-6723.14290] [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: 02/28/2023] [Revised: 05/17/2023] [Accepted: 07/19/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first-line for outpatient stable chest pain evaluation was implemented in an Australian ED. METHODS In pre-post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6-month pre-implementation group (February 2021 to July 2021). CTCA was recommended first-line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. RESULTS Three hundred and fifteen patients were included, 143 pre-implementation and 172 post-implementation. Characteristics were similar except age (pre-implementation: 58.9 ± 12.0 vs post-implementation: 62.8 ± 12.3 years, P = 0.004). Pathway-guided management resulted in higher first-line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non-invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre-implementation: 13.3% vs post-implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post-implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30-day myocardial infarction or death occurred. CONCLUSIONS The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.
Collapse
Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia, Australia
| | - David-Raj Thomas
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher L Jones
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Vikram Raju
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeanette Soon
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacobus Otto
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Chris Wood
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
5
|
Greer C, Williams MC, Newby DE, Adamson PD. Role of computed tomography cardiac angiography in acute chest pain syndromes. Heart 2023; 109:1350-1356. [PMID: 36914247 DOI: 10.1136/heartjnl-2022-321360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
Use of CT coronary angiography (CTCA) to evaluate chest pain has rapidly increased over the recent years. While its utility in the diagnosis of coronary artery disease in stable chest pain syndromes is clear and is strongly endorsed by international guidelines, the role of CTCA in the acute setting is less certain. In the low-risk setting, CTCA has been shown to be accurate, safe and efficient but inherent low rates of adverse events in this population and the advent of high-sensitivity troponin testing have left little room for CTCA to show any short-term clinical benefit.In higher-risk populations, CTCA has potential to fulfil a gatekeeper role to invasive angiography. The high negative predictive value of CTCA is maintained while also identifying non-obstructive coronary disease and alternative diagnoses in the substantial group of patients presenting with chest pain who do not have type 1 myocardial infarction. For those with obstructive coronary disease, CTCA provides accurate assessment of stenosis severity, characterisation of high-risk plaque and findings associated with perivascular inflammation. This may allow more appropriate selection of patients to proceed to invasive management with no disadvantage in outcomes and can provide a more comprehensive risk stratification to guide both acute and long-term management than routine invasive angiography.
Collapse
Affiliation(s)
- Charlotte Greer
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
| | | | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
6
|
Barbosa MF, Canan A, Xi Y, Litt H, Diercks DB, Abbara S, Kay FU. Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta-Analysis. Radiol Cardiothorac Imaging 2023; 5:e230022. [PMID: 37693194 PMCID: PMC10483255 DOI: 10.1148/ryct.230022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 09/12/2023]
Abstract
Purpose To perform a living systematic review and meta-analysis of randomized controlled trials comparing the effectiveness of coronary CT angiography (CCTA) and standard of care (SOC) in the evaluation of acute chest pain (ACP). Materials and Methods Multiple electronic databases were systematically searched, with the most recent search conducted on October 31, 2022. Studies were stratified into two groups according to the pretest probability for acute coronary syndrome (group 1 with predominantly low-to-intermediate risk vs group 2 with high risk). A meta-regression analysis was also conducted using participant risk, type of SOC used, and the use or nonuse of high-sensitivity troponins as independent variables. Results The final analysis included 22 randomized controlled trials (9379 total participants; 4956 assigned to CCTA arms and 4423 to SOC arms). There was a 14% reduction in the length of stay and a 17% reduction in immediate costs for the CCTA arm compared with the SOC arm. In group 1, the length of stay was 17% shorter and costs were 21% lower using CCTA. There was no evidence of differences in referrals to invasive coronary angiography, myocardial infarction, mortality, rate of hospitalization, further stress testing, or readmissions between CCTA and SOC arms. There were more revascularizations (relative risk, 1.45) and medication changes (relative risk, 1.33) in participants with low-to-intermediate acute coronary syndrome risk and increased radiation exposure in high-risk participants (mean difference, 7.24 mSv) in the CCTA arm compared with the SOC arm. The meta-regression analysis found significant differences between CCTA and SOC arms for rate of hospitalization, further stress testing, and medication changes depending on the type of SOC (P < .05). Conclusion The results support the use of CCTA as a safe, rapid, and less expensive in the short term strategy to exclude acute coronary syndrome in low- to intermediate-risk patients presenting with acute chest pain.Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Department, Coronary Computed Tomography, Usual Care Supplemental material is available for this article. Published under a CC BY 4.0 license.
Collapse
Affiliation(s)
- Maurício F. Barbosa
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Arzu Canan
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Yin Xi
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Harold Litt
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Deborah B. Diercks
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Suhny Abbara
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Fernando U. Kay
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| |
Collapse
|
7
|
Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [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: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
Collapse
Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | | |
Collapse
|
8
|
Pugliese L, Ricci F, Sica G, Scaglione M, Masala S. Non-Contrast and Contrast-Enhanced Cardiac Computed Tomography Imaging in the Diagnostic and Prognostic Evaluation of Coronary Artery Disease. Diagnostics (Basel) 2023; 13:2074. [PMID: 37370969 DOI: 10.3390/diagnostics13122074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
In recent decades, cardiac computed tomography (CT) has emerged as a powerful non-invasive tool for risk stratification, as well as the detection and characterization of coronary artery disease (CAD), which remains the main cause of morbidity and mortality in the world. Advances in technology have favored the increasing use of cardiac CT by allowing better performance with lower radiation doses. Coronary artery calcium, as assessed by non-contrast CT, is considered to be the best marker of subclinical atherosclerosis, and its use is recommended for the refinement of risk assessment in low-to-intermediate risk individuals. In addition, coronary CT angiography (CCTA) has become a gate-keeper to invasive coronary angiography (ICA) and revascularization in patients with acute chest pain by allowing the assessment not only of the extent of lumen stenosis, but also of its hemodynamic significance if combined with the measurement of fractional flow reserve or perfusion imaging. Moreover, CCTA provides a unique incremental value over functional testing and ICA by imaging the vessel wall, thus allowing the assessment of plaque burden, composition, and instability features, in addition to perivascular adipose tissue attenuation, which is a marker of vascular inflammation. There exists the potential to identify the non-obstructive lesions at high risk of progression to plaque rupture by combining all of these measures.
Collapse
Affiliation(s)
- Luca Pugliese
- Radiology Unit, Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, 00189 Rome, Italy
| | - Francesca Ricci
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Giacomo Sica
- Radiology Unit, Monaldi Hospital, 80131 Napoli, Italy
| | - Mariano Scaglione
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Salvatore Masala
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| |
Collapse
|
9
|
Kumar K, Seetharam K, Rani T, Mir P, Mir T, Shetty V, Shani J. Evolution of Stress Echocardiogram in the Era of CT Angiography. Cureus 2023; 15:e39501. [PMID: 37378169 PMCID: PMC10292127 DOI: 10.7759/cureus.39501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
The ideal diagnostic modality for acute chest pain is a highly debated topic in the cardiovascular community. With the rapid rise of coronary computed tomography angiography (CTA) and the fall of functional testing, stress echocardiography (SE) is at a delicate crossroads. Though there are many advantages of coronary CTA, it is not without its flaws. The exact realm of SE needs to be clearly defined, as well as which patients need diagnostic testing. The emergence of additional parameters will propel the evolution of modern SE. In this review article, we explore the role of SE, guidelines, comparison of SE versus CTA, and additional parameters in the coronary CTA era.
Collapse
Affiliation(s)
- Kelash Kumar
- Internal Medicine, Maimonides Medical Center, New York, USA
| | | | - Teesha Rani
- Medicine and Surgery, Ziauddin University, Karachi, PAK
| | - Parvez Mir
- Internal Medicine and Pulmonology, Wyckoff Heights Medical Center, New York, USA
| | - Tanveer Mir
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Vijay Shetty
- Internal Medicine and Cardiology, Maimonides Medical Center, New York, USA
| | - Jacob Shani
- Cardiology, Maimonides Medical Center, New York, USA
| |
Collapse
|
10
|
Garg Y, Seetharam K, Sharma M, Rohita DK, Nabi W. Role of Deep Learning in Computed Tomography. Cureus 2023; 15:e39160. [PMID: 37332431 PMCID: PMC10275744 DOI: 10.7759/cureus.39160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
Computed tomography has played an instrumental role in the understanding of the pathophysiology of atherosclerosis in coronary artery disease. It enables visualization of the plaque obstruction and vessel stenosis in a comprehensive manner. As technology for computed tomography is constantly evolving, coronary applications and possibilities are constantly expanding. This influx of information can overwhelm a physician's ability to interpret information in this era of big data. Machine learning is a revolutionary approach that can help provide limitless pathways in patient management. Within these machine algorithms, deep learning has tremendous potential and can revolutionize computed tomography and cardiovascular imaging. In this review article, we highlight the role of deep learning in various aspects of computed tomography.
Collapse
Affiliation(s)
- Yash Garg
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | | | - Manjari Sharma
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Dipesh K Rohita
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Waseem Nabi
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| |
Collapse
|
11
|
Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
Collapse
Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
| |
Collapse
|
12
|
Premaratne M, Garcia GP, Thomas W, Hameed S, Leadbeatter A, Htun N, Dwivedi G, Kaye DM. Opportunities and Challenges of Computed Tomography Coronary Angiography in the Investigation of Chest Pain in the Emergency Department-A Narrative Review. Heart Lung Circ 2023; 32:307-314. [PMID: 36621394 DOI: 10.1016/j.hlc.2022.12.004] [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: 05/22/2022] [Revised: 11/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Chest pain is one of the most common presentations to emergency departments. However, only 5.1% will be diagnosed with an acute coronary syndrome, representing considerable time and expense in the diagnosis and investigation of the patients eventually found not to be suffering from an acute coronary syndrome. PubMed and Medline databases were searched with variations of the terms "chest pain", "emergency department", "computed tomography coronary angiography". After review, 52 articles were included. Computed tomography coronary angiography (CTCA) is a class I endorsement for investigating chest pain in major international societal guidelines. CTCA offers excellent sensitivity and negative predictive value in identifying patients with coronary disease, with prognostic data impacting patient management. If CTCA is to be applied to all comers, it is pertinent to discuss the advantages and potential pitfalls if use in the Australian system is to be increased.
Collapse
Affiliation(s)
- Manuja Premaratne
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia.
| | | | - William Thomas
- Department of Radiology, Peninsula Health, Melbourne, Vic, Australia
| | - Shaiq Hameed
- Department of Medicine, Peninsula Health, Melbourne, Vic, Australia
| | | | - Nay Htun
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Girish Dwivedi
- Department of Cardiology, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| |
Collapse
|
13
|
Maroules CD, Rybicki FJ, Ghoshhajra BB, Batlle JC, Branch K, Chinnaiyan K, Hamilton-Craig C, Hoffmann U, Litt H, Meyersohn N, Shaw LJ, Villines TC, Cury RC. 2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: An expert consensus document of the Society of cardiovascular computed tomography (SCCT): Endorsed by the American College of Radiology (ACR) and North American Society for cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2023; 17:146-163. [PMID: 36253281 DOI: 10.1016/j.jcct.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
Coronary computed tomography angiography (CTA) improves the quality of care for patients presenting with acute chest pain (ACP) to the emergency department (ED), particularly in patients with low to intermediate likelihood of acute coronary syndrome (ACS). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of coronary CTA to ensure appropriate, safe, and efficient use of this modality. Because of the increasing use of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients in the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.
Collapse
Affiliation(s)
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Juan C Batlle
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA
| | - Kelley Branch
- Department of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Harold Litt
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nandini Meyersohn
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Todd C Villines
- Department of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ricardo C Cury
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA
| |
Collapse
|
14
|
Ihdayhid AR, Lan NSR, Figtree GA, Patel S, Arnott C, Hamilton-Craig C, Psaltis PJ, Leipsic J, Fairbairn T, Wahi S, Hillis GS, Rankin JM, Dwivedi G, Nicholls SJ. Contemporary Chest Pain Evaluation: The Australian Case for Cardiac CT. Heart Lung Circ 2023; 32:297-306. [PMID: 36610819 DOI: 10.1016/j.hlc.2022.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/07/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.
Collapse
Affiliation(s)
- Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, Curtin University, Perth, WA, Australia.
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sanjay Patel
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Cardiovascular Division, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Peter J Psaltis
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Jonathon Leipsic
- University of British Columbia, St Paul's Hospital, Vancouver, Canada
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Graham S Hillis
- Department of Cardiology and University of Western Australia, Royal Perth Hospital, Perth, WA, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| |
Collapse
|
15
|
Wang KL, Meah MN, Bularga A, Singh T, Williams MC, Newby DE. Computed tomography coronary angiography in non-ST-segment elevation myocardial infarction. Br J Radiol 2022; 95:20220346. [PMID: 36017975 PMCID: PMC9733606 DOI: 10.1259/bjr.20220346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022] Open
Abstract
Electrocardiography and high-sensitivity cardiac troponin testing are routinely applied as the initial step for clinical evaluation of patients with suspected non-ST-segment elevation myocardial infarction. Once diagnosed, patients with non-ST-segment elevation myocardial infarction are commenced on antithrombotic and secondary preventative therapies before undergoing invasive coronary angiography to determine the strategy of coronary revascularisation. However, this clinical pathway is imperfect and can lead to challenges in the diagnosis, management, and clinical outcomes of these patients. Computed tomography coronary angiography (CTCA) has increasingly been utilised in the setting of patients with suspected non-ST-segment elevation myocardial infarction, where it has an important role in avoiding unnecessary invasive coronary angiography and reducing downstream non-invasive functional testing for myocardial ischaemia. CTCA is an excellent gatekeeper for the cardiac catheterisation laboratory. In addition, CTCA provides complementary information for patients with myocardial infarction in the absence of obstructive coronary artery disease and highlights alternative or incidental diagnoses for those with cardiac troponin elevation. However, the routine application of CTCA has yet to demonstrate an impact on subsequent major adverse cardiovascular events. There are several ongoing studies evaluating CTCA and its associated technologies that will define and potentially expand its application in patients with suspected or diagnosed non-ST-segment elevation myocardial infarction. We here review the current evidence relating to the clinical application of CTCA in patients with non-ST-segment elevation myocardial infarction and highlight the areas where CTCA is likely to have an increasing important role and impact for our patients.
Collapse
Affiliation(s)
| | - Mohammed N Meah
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Trisha Singh
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
16
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). JACC Cardiovasc Imaging 2022; 15:1974-2001. [PMID: 36115815 DOI: 10.1016/j.jcmg.2022.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | - Daniel Berman
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marcio Bittencourt
- Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, New York, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, North Carolina, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, Arizona, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Eric Williamson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
17
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System.: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). J Am Coll Radiol 2022; 19:1185-1212. [PMID: 36436841 DOI: 10.1016/j.jacr.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, 8900 N Kendall Drive, Miami FL, 33176, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, NY, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, NC, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
18
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2022; 16:536-557. [PMID: 35864070 DOI: 10.1016/j.jcct.2022.07.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami FL, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, NY, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, NC, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
19
|
Dahal S, Budoff MJ, Roy SK. Coronary Computed Tomography Angiography for Evaluation of Chest Pain in the Emergency Department. Tex Heart Inst J 2022; 49:e217550. [PMID: 36511943 PMCID: PMC9809099 DOI: 10.14503/thij-21-7550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronary computed tomography angiography has emerged as an important diagnostic modality for evaluation of acute chest pain in the emergency department for patients at low to intermediate risk for acute coronary syndromes. Several clinical trials have shown excellent negative predictive value of coronary computed tomography angiography to detect obstructive coronary artery disease. Cardiac biomarkers such as troponins and creatine kinase MB, along with history, electrocardiogram, age, risk factors, troponin score, and Thrombolysis in Myocardial Infarction score should be used in conjunction with coronary computed tomography angiography for safe and rapid discharge of patients from the emergency department. Coronary computed tomography angiography along with high-sensitivity troponin assays could be effective for rapid evaluation of acute chest pain in the emergency department, but high-sensitivity troponins are not always available. Emergency department physicians are not quite comfortable making clinical decisions, especially if the coronary stenosis is in the range of 50% to 70%. In these cases, further evaluation with functional testing, such as nuclear stress testing or stress echocardiogram, is a common approach in many centers; however, newer methods such as fractional flow reserve computed tomography could be safely incorporated in coronary computed tomography angiography to help with clinical decision-making in these scenarios.
Collapse
Affiliation(s)
- Suraj Dahal
- Department of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Matthew J. Budoff
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
| | - Sion K. Roy
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
| |
Collapse
|
20
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). Radiol Cardiothorac Imaging 2022; 4:e220183. [PMID: 36339062 PMCID: PMC9627235 DOI: 10.1148/ryct.220183] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 06/16/2023]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care. Keywords: Coronary Artery Disease, Coronary CTA, CAD-RADS, Reporting and Data System, Stenosis Severity, Report Standardization Terminology, Plaque Burden, Ischemia Supplemental material is available for this article. This article is published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, JACC: Cardiovascular Imaging, Journal of the American College of Radiology, and International Journal for Cardiovascular Imaging. © 2022 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.
Collapse
Affiliation(s)
- Ricardo C. Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South
Florida, 8900 N Kendall Drive, Miami FL, 33176, USA
| | | | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX,
USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology,
Ulmenweg 18, 90154, Erlangen, Germany
| | | | | | | | | | - Andrew D. Choi
- The George Washington University School of Medicine, USA
| | | | - Jill Jacobs
- NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016,
USA
| | | | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, USA
| | | | | | - Frank J. Rybicki
- Department of Radiology, University of Cincinnati College of
Medicine, USA
| | | | | | | | | | - Todd C. Villines
- Division of Cardiology, University of Virginia Health System,
USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School,
USA
| |
Collapse
|
21
|
Meng H, Ruan J, Yan Z, Chen Y, Liu J, Li X, Meng F. New Progress in Early Diagnosis of Atherosclerosis. Int J Mol Sci 2022; 23:ijms23168939. [PMID: 36012202 PMCID: PMC9409135 DOI: 10.3390/ijms23168939] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 11/18/2022] Open
Abstract
Coronary atherosclerosis is a potentially chronic circulatory condition that endangers human health. The biological cause underpinning cardiovascular disease is coronary atherosclerosis, and acute cardiovascular events can develop due to thrombosis, platelet aggregation, and unstable atherosclerotic plaque rupture. Coronary atherosclerosis is progressive, and three specific changes appear, with fat spots and stripes, atherosclerosis and thin-walled fiber atherosclerosis, and then complex changes in arteries. The progression and severity of cardiovascular disease are correlated with various levels of calcium accumulation in the coronary artery. The therapy and diagnosis of coronary atherosclerosis benefit from the initial assessment of the size and degree of calcification. This article will discuss the new progress in the early diagnosis of coronary atherosclerosis in terms of three aspects: imaging, gene and protein markers, and trace elements. This study intends to present the latest methods for diagnosing patients with early atherosclerosis through a literature review.
Collapse
Affiliation(s)
- Heyu Meng
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Jianjun Ruan
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Zhaohan Yan
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Yanqiu Chen
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Jinsha Liu
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Xiangdong Li
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Fanbo Meng
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Correspondence: ; Tel.: +86-15948346855
| |
Collapse
|
22
|
Gray AJ, Roobottom C, Smith JE, Goodacre S, Oatey K, O'Brien R, Storey RF, Curzen N, Keating L, Kardos A, Felmeden D, Lee RJ, Thokala P, Lewis SC, Newby DE. Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT. Health Technol Assess 2022; 26:1-114. [PMID: 36062819 DOI: 10.3310/irwi5180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. OBJECTIVE To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. DESIGN A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. SETTING Thirty-seven hospitals in the UK. PARTICIPANTS Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. INTERVENTIONS Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. MAIN OUTCOME MEASURE One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. RESULTS Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. LIMITATIONS The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. FUTURE WORK The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. CONCLUSIONS In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. TRIAL REGISTRATION This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Alasdair J Gray
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton and Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Robert J Lee
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
23
|
Added Value of CCTA-Derived Features to Predict MACEs in Stable Patients Undergoing Coronary Computed Tomography. Diagnostics (Basel) 2022; 12:diagnostics12061446. [PMID: 35741256 PMCID: PMC9222004 DOI: 10.3390/diagnostics12061446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/05/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
Clinical evidence has emphasized the importance of coronary plaques’ characteristics, rather than lumen stenosis, for the outcome of cardiovascular events. Coronary computed tomographic angiography (CCTA) has a well-established role as a non-invasive tool for assessing plaques. The aim of this study was to compare clinical characteristics and CCTA-derived information of stable patients with non-severe plaques in predicting major adverse cardiac events (MACEs) during follow-up. We retrospectively selected 371 patients (64% male) who underwent CCTA in our center from March 2016 to January 2021 with Coronary Artery Disease—Reporting and Data System (CAD-RADS) 0 to 3. Of those, 198 patients (53% male) had CAD-RADS 0 to 1. Among them, 183 (49%) had normal pericoronary fat attenuation index (pFAI), while 15 (60% male) had pFAI ≥ 70.1 Hounsfield unit (HU). The remaining 173 patients (76% male) had CAD-RADS 2 to 3 and were divided into patients with at least one low attenuation plaque (LAP) and patients without LAPs (n-LAP). Compared to n-LAP, patients with LAPs had higher pFAI (p = 0.005) and had more plaques than patients with n-LAP. Presence of LAPs was significantly higher in elderly (p < 0.001), males (p < 0.001) and patients with traditional risk factors (hypertension p = 0.0001, hyperlipemia p = 0.0003, smoking p = 0.0003, diabetes p = <0.0001, familiarity p = 0.0007). Among patients with CAD-RADS 0 to 1, the ones with pFAI ≥ 70.1 HU were more often hyperlipidemic (p = 0.05) and smokers (p = 0.007). Follow-up (25,4 months, range: 17.6−39.2 months) demonstrated that LAP and pFAI ≥ 70.1 significantly and independently (p = 0.04) predisposed to outcomes (overall mortality and interventional procedures). There is an added value of CCTA-derived features in stratifying cardiovascular risk in low- to intermediate-risk patients with non-severe, non-calcified coronary plaques. This is of utmost clinical relevance as it is possible to identify a subset of patients with increased risk who need strengthening in therapeutic management and closer follow-up even in the absence of severe CAD. Further studies are needed to evaluate the effect of medical treatments on pericoronary inflammation and plaque composition.
Collapse
|
24
|
Mehta P, McDonald S, Hirani R, Good D, Diercks D. Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis. Acad Emerg Med 2022; 29:748-764. [PMID: 34741781 DOI: 10.1111/acem.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low- to intermediate-risk patients. METHODS Initially, 952 articles were identified for screening, 81 met criteria for full-text review, and once risk of bias was assessed, 33 articles were included in this meta-analysis. We utilized a random-effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low- to intermediate-risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q-test and I2 statistic. RESULTS Twenty-one studies evaluated follow-up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within-group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). CONCLUSIONS Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.
Collapse
Affiliation(s)
- Prayag Mehta
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raiz Hirani
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Good
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
25
|
Ranjan P, Ro R, Lerakis S. Multislice Computed Tomography (MSCT) and Cardiovascular Magnetic Resonance (CMR) Imaging for Coronary and Structural Heart Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
|
26
|
Carrabba N, Pontone G, Andreini D, Buffa V, Cademartiri F, Carbone I, Clemente A, Guaricci AI, Guglielmo M, Indolfi C, La Grutta L, Ligabue G, Liguori C, Mercuro G, Mushtaq S, Neglia D, Palmisano A, Sciagrà R, Seitun S, Vignale D, Francone M, Esposito A. Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation. J Cardiovasc Med (Hagerstown) 2022; 23:290-303. [PMID: 35486680 DOI: 10.2459/jcm.0000000000001303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.
Collapse
Affiliation(s)
- Nazario Carrabba
- Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence
| | | | - Daniele Andreini
- Centro Cardiologico Monzino IRCCS.,Department of Clinical Sciences and Community Health, University of Milan, Milan
| | - Vitaliano Buffa
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Rome
| | | | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari
| | | | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro
| | - Ludovico La Grutta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties-ProMISE, University of Palermo
| | - Guido Ligabue
- Department of Medical and Surgical Sciences, Modena and Raggio Emilia University.,Radiology Department, AOU of Modena, Modena
| | - Carlo Liguori
- Radiology Unit, Ospedale del Mare -A.S.L Na1- Centro, Naples
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | | | - Danilo Neglia
- Cardiovascular Department, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Pisa
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence
| | - Sara Seitun
- Radiology Department, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia e le Neuroscienze, Genoa, Italy
| | - Davide Vignale
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| |
Collapse
|
27
|
Khawaja T, Janus S, Al-Kindi SG. Role of Coronary CT Angiography in the Evaluation of Acute Chest Pain and Suspected or Confirmed Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Advances in CT technology have resulted in improved imaging of the coronary anatomy in patients with stable coronary artery disease, using coronary CT angiography (CCTA). Recent data suggest that CCTA may play a role in higher risk patients, such as those evaluated in the emergency room with acute chest pain. Data thus far support the use of CCTA in low-risk patients with acute chest pain. Recent literature suggests that CCTA may play a role in the risk stratification of selected intermediate-risk patients. In this review, the authors discuss the emerging role of CCTA in higher risk patients, such as those with suspected or confirmed acute coronary syndrome (ACS). The excellent accuracy of CCTA in detecting obstructive coronary artery disease in patients with ACS is detailed, along with a highlighting of the safety of using CCTA in this setting. The authors also discuss the role for CCTA atheromatous plaque characterization, which is being increasingly recognized as an important predictor of clinical outcomes.
Collapse
Affiliation(s)
- Tasveer Khawaja
- Department of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH
| | - Scott Janus
- Department of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH
| | - Sadeer G Al-Kindi
- Department of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH
| |
Collapse
|
28
|
Budoff MJ, Lakshmanan S, Toth PP, Hecht HS, Shaw LJ, Maron DJ, Michos ED, Williams KA, Nasir K, Choi AD, Chinnaiyan K, Min J, Blaha M. Cardiac CT angiography in current practice: An American society for preventive cardiology clinical practice statement ✰. Am J Prev Cardiol 2022; 9:100318. [PMID: 35146468 PMCID: PMC8802838 DOI: 10.1016/j.ajpc.2022.100318] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022] Open
Abstract
In this clinical practice statement, we represent a summary of the current evidence and clinical applications of cardiac computed tomography (CT) in evaluation of coronary artery disease (CAD), from an expert panel organized by the American Society for Preventive Cardiology (ASPC), and appraises the current use and indications of cardiac CT in clinical practice. Cardiac CT is emerging as a front line non-invasive diagnostic test for CAD, with evidence supporting the clinical utility of cardiac CT in diagnosis and prevention. CCTA offers several advantages beyond other testing modalities, due to its ability to identify and characterize coronary stenosis severity and pathophysiological changes in coronary atherosclerosis and stenosis, aiding in early diagnosis, prognosis and management of CAD. This document further explores the emerging applications of CCTA based on functional assessment using CT derived fractional flow reserve, peri‑coronary inflammation and artificial intelligence (AI) that can provide personalized risk assessment and guide targeted treatment. We sought to provide an expert consensus based on the latest evidence and best available clinical practice guidelines regarding the role of CCTA as an essential tool in cardiovascular prevention - applicable to risk assessment and early diagnosis and management, noting potential areas for future investigation.
Collapse
Affiliation(s)
- Matthew J. Budoff
- Division of Cardiology, Lundquist Institute at Harbor-UCLA, Torrance CA, USA
| | - Suvasini Lakshmanan
- Division of Cardiology, Lundquist Institute at Harbor-UCLA, Torrance CA, USA
| | - Peter P. Toth
- CGH Medical Center, Sterling, IL and Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Harvey S. Hecht
- Department of Medicine, Mount Sinai Medical Center, New York, NY
| | - Leslee J. Shaw
- Department of Medicine (Cardiology), Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J. Maron
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kim A. Williams
- Division of Cardiology, Rush University Medical Center, Chicago IL
| | - Khurram Nasir
- Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Andrew D. Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Kavitha Chinnaiyan
- Division of Cardiology, Department of Medicine, Beaumont Hospital, Royal Oak, MI
| | - James Min
- Chief Executive Officer Cleerly Inc., New York, NY
| | - Michael Blaha
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
29
|
Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I. Eur Heart J Cardiovasc Imaging 2022; 23:299-314. [PMID: 35076061 PMCID: PMC8863074 DOI: 10.1093/ehjci/jeab293] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/14/2021] [Indexed: 01/26/2023] Open
Abstract
Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.
Collapse
Affiliation(s)
- Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
| |
Collapse
|
30
|
Mansour HH, Alajerami YS, Abushab KM, Quffa KM. The diagnostic accuracy of coronary computed tomography angiography in patients with and without previous coronary interventions. J Med Imaging Radiat Sci 2022; 53:81-86. [PMID: 34987013 DOI: 10.1016/j.jmir.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Invasive coronary angiography (ICA) is the gold standard for imaging coronary arteries and the severity of coronary artery disease (CAD). Coronary computed tomography angiography (CCTA) has undergone remarkable progress in the diagnosis of CAD. OBJECTIVES To evaluate the effect of prior vs no previous coronary interventions on the diagnostic accuracy of CCTA as an alternative to ICA to improve health outcomes for patients with suspected CAD. METHODS A prospective cohort study was carried out among patients suspected of CAD and for evaluation of grafts and stents to investigate recurrent ischemic symptoms. 120 patients imaged by CCTA were then referred to ICA, which is considered the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CCTA were assessed relative to ICA. RESULTS Based on a per-patient analysis, the comparison with ICA reveals variations in sensitivity, specificity, PPV, NPV and accuracy of CCTA. In patients without any previous coronary interventions, the sensitivity was 97.8%, and specificity was 95.6%. The PPV and NPV were 97.8% and 95.5%, respectively. Regarding patients with coronary artery bypass grafts (CABG), the sensitivity was 95% and specificity 100%. The PPV and NPV were 100% and 90.9%, respectively. Regarding patients with prior percutaneous coronary intervention (PCI), the results were a sensitivity of 84.6%, specificity of 77.8%, PPV of 84.6% and NPV of 77.8%. CONCLUSION CCTA is a powerful diagnostic tool, especially for the evaluation of the major coronary arteries and evaluation of patients with prior CABG. ICA is recommended for evaluation of patients with an intracoronary stent.
Collapse
Affiliation(s)
- Husam H Mansour
- Radiology Department, Al-Shifa Hospital, Gaza-Palestine, Palestine; Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine.
| | - Yasser S Alajerami
- Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine
| | - Khaled M Abushab
- Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine
| | - Khetam M Quffa
- Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine
| |
Collapse
|
31
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Collapse
|
32
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 299] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Collapse
|
33
|
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
Collapse
|
34
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Collapse
|
35
|
Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
Collapse
|
36
|
Lee KK, Bularga A, O'Brien R, Ferry AV, Doudesis D, Fujisawa T, Kelly S, Stewart S, Wereski R, Cranley D, van Beek EJR, Lowe DJ, Newby DE, Williams MC, Gray AJ, Mills NL. Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction. J Am Coll Cardiol 2021; 78:1407-1417. [PMID: 34593122 PMCID: PMC8482793 DOI: 10.1016/j.jacc.2021.07.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with suspected acute coronary syndrome in whom myocardial infarction has been excluded are at risk of future adverse cardiac events. OBJECTIVES This study evaluated the usefulness of high-sensitivity cardiac troponin I (hs-cTnI) to select patients for further investigation after myocardial infarction has been excluded. METHODS This is a prospective cohort study of patients presenting to the emergency department with suspected acute coronary syndrome and hs-cTnI concentrations below the sex-specific 99th percentile. Patients were recruited in a 2:1 fashion, stratified by peak hs-cTnI concentration above and below the risk stratification threshold of 5 ng/L. All patients underwent coronary computed tomography angiography (CCTA) after hospital discharge. RESULTS Overall, 250 patients were recruited (61.4 ± 12.2 years 31% women) in whom 62.4% (156 of 250 patients) had coronary artery disease (CAD). Patients with intermediate hs-cTnI concentrations (between 5 ng/L and the sex-specific 99th percentile) were more likely to have CAD than those with hs-cTnI concentrations <5 ng/L (71.9% [120 of 167 patients] vs 43.4% [36 of 83 patients]; odds ratio: 3.33; 95% CI: 1.92-5.78). Conversely, there was no association between anginal symptoms and CAD (63.2% [67 of 106 patients] vs 61.8% [89 of 144 patients]; odds ratio: 0.92; 95% CI: 0.48-1.76). Most patients with CAD did not have a previous diagnosis (53.2%; 83 of 156 patients) and were not on antiplatelet and statin therapies (63.5%; 99 of 156 patients) before they underwent CCTA. CONCLUSIONS In patients who had myocardial infarction excluded, CAD was 3× more likely in those with intermediate hs-cTnI concentrations compared with low hs-cTnI concentrations. In such patients, CCTA could help to identify those with occult CAD and to target preventative treatments, thereby improving clinical outcomes.
Collapse
Affiliation(s)
- Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rachel O'Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Shauna Kelly
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Stacey Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Denise Cranley
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Edwin J R van Beek
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging Facility QMRI (The Queen's Medical Research Institute), University of Edinburgh, Edinburgh, United Kingdom
| | - David J Lowe
- University of Glasgow, School of Medicine, Glasgow, United Kingdom
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging Facility QMRI (The Queen's Medical Research Institute), University of Edinburgh, Edinburgh, United Kingdom
| | - Alasdair J Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom.
| |
Collapse
|
37
|
Leong CL, Teoh TW, Bentley L, O'Rourke E, Allright A, Werkmeister M, Bickell A, Htun NM, Premaratne M. Resource implications following expansion of computed tomography coronary angiography: An Australian experience. J Med Imaging Radiat Oncol 2021; 66:623-627. [PMID: 34541762 DOI: 10.1111/1754-9485.13331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION To determine the downstream utilisation of Computed Tomography Coronary Angiography (CTCA) in a single Australian tertiary centre. METHODS A single-centre retrospective study analysed 1460 patients undergoing CTCA between 1st January 2015 to 31st December 2018 at a tertiary hospital in Victoria, Australia, with a catchment area of 500,000 people. The coronary stenosis grading, plaque characteristics and coronary calcium score were identified. The downstream impact was assessed by measuring the number of stress echocardiograms, myocardial perfusion scans (MPS), invasive coronary angiograms and subsequent revascularisations. RESULTS The number of CTCA's performed steadily increased from 59 in 2015 to 395, 461 and 545 in 2016, 2017 and 2018 respectively. Seven hundred and fifty-seven (52%) were females, and 703 (48%) males with 724 (50%) normal CTCA studies. The number of downstream stress echocardiogram performed each year was 2, 60, 46 and 16, respectively, accompanied by MPS numbers of 0, 21, 29, and 18. There were 9, 37, 57 and 64 invasive coronary angiograms with 1, 13, 19 and 22 corresponding revascularisations. Despite small increases in absolute numbers of patients presenting with chest pain (from 2678 in 2015 to 3660 in 2018), there was a significant increase in downstream further testing from 11 in 2015 to 98 in 2018. CONCLUSION The use of CTCA expansion has resulted in an increase in downstream testing. Therefore, resource planning with regards to CTCA expansion will have to account for increased rates of functional testing, invasive angiography and revascularisation.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Nay Min Htun
- Peninsula Health, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Manuja Premaratne
- Peninsula Health, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
38
|
Serruys PW, Hara H, Garg S, Kawashima H, Nørgaard BL, Dweck MR, Bax JJ, Knuuti J, Nieman K, Leipsic JA, Mushtaq S, Andreini D, Onuma Y. Coronary Computed Tomographic Angiography for Complete Assessment of Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:713-736. [PMID: 34384554 DOI: 10.1016/j.jacc.2021.06.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 01/09/2023]
Abstract
Coronary computed tomography angiography (CTA) has shown great technological improvements over the last 2 decades. High accuracy of CTA in detecting significant coronary stenosis has promoted CTA as a substitute for conventional invasive coronary angiography in patients with suspected coronary artery disease. In patients with coronary stenosis, CTA-derived physiological assessment is surrogate for intracoronary pressure and velocity wires, and renders possible decision-making about revascularization solely based on computed tomography. Computed tomography coronary anatomy with functionality assessment could potentially become a first line in diagnosis. Noninvasive imaging assessment of plaque burden and morphology is becoming a valuable substitute for intravascular imaging. Recently, wall shear stress and perivascular inflammation have been introduced. These assessments could support risk management for both primary and secondary cardiovascular prevention. Anatomy, functionality, and plaque composition by CTA tend to replace invasive assessment. Complete CTA assessment could provide a 1-stop-shop for diagnosis, risk management, and decision-making on treatment.
Collapse
Affiliation(s)
- Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; NHLI, Imperial College London, London, United Kingdom.
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. https://twitter.com/hara_hironori
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Juhani Knuuti
- Heart Center, Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| |
Collapse
|
39
|
England RW, Sheikhbahaei S, Solomon AJ, Arbab-Zadeh A, Solnes LB, Bronner J, Johnson PT. When More Is Better: Underused Advanced Imaging Exams That Can Improve Outcomes and Reduce Cost of Care. Am J Med 2021; 134:848-853.e1. [PMID: 33819488 DOI: 10.1016/j.amjmed.2021.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 12/11/2022]
Abstract
Appropriate use of resources is a tenet of care transformation efforts, with a national campaign to reduce low-value imaging. The next level of performance improvement is to bolster evidence-based screening, imaging surveillance, and diagnostic innovation, which can avert more costly, higher-risk elements of unnecessary care like emergent interventions. Clinical scenarios in which underused advanced imaging can improve outcomes and reduce total cost of care are reviewed, including abdominal aortic aneurysm surveillance, coronary artery disease diagnosis, and renal mass characterization. Reliable abdominal aortic aneurysm surveillance imaging reduces emergency surgery and can be driven by radiologists incorporating best practice standardized recommendations in imaging interpretations. Coronary computed tomography angiography in patients with stable and unstable chest pain can reduce downstream resource use while improving outcomes. Preoperative 99mTc-sestamibi single-photon emission computed tomography (SPECT) reliably distinguishes oncocytoma from renal cell carcinoma to obviate unnecessary nephrectomy. As technological advances in diagnostic, molecular, and interventional radiology improve our ability to detect and cure disease, analyses of cost effectiveness will be critical to radiology leadership and sustainability in the transition to a value-based reimbursement model.
Collapse
Affiliation(s)
| | | | | | - Armin Arbab-Zadeh
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Jay Bronner
- Radiology Partners Research Institute, El Segundo, Calif
| | | |
Collapse
|
40
|
Branch KRH, Strote J, Gunn M, Maynard C, Kudenchuk PJ, Brusen R, Petek BJ, Sayre MR, Edwards R, Carlbom D, Counts CR, Probstfield JL, Gatewood MO. Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology. Acad Emerg Med 2021; 28:394-403. [PMID: 33606342 DOI: 10.1111/acem.14228] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 01/31/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. METHODS From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. RESULTS SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. CONCLUSIONS This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.
Collapse
Affiliation(s)
| | - Jared Strote
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | - Martin Gunn
- Department of Radiology Harborview Medical Center Seattle Washington USA
| | - Charles Maynard
- Department of Health Services School of Public Health and Community Medicine University of Washington Seattle Washington USA
| | - Peter J. Kudenchuk
- Department of Cardiology University of Washington Seattle Washington USA
| | | | - Bradley J. Petek
- Internal Medicine Massachusetts General Hospital Boston Washington USA
| | - Michael R. Sayre
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | - Rachael Edwards
- Department of Radiology Harborview Medical Center Seattle Washington USA
| | - David Carlbom
- Pulmonary Critical Care and Sleep Medicine Harborview Medical Center Seattle Washington USA
| | - Catherine R. Counts
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Medley O. Gatewood
- Department of Emergency Medicine University of Washington Seattle Washington USA
| |
Collapse
|
41
|
Kumar P, Bhatia M. Coronary Artery Disease Reporting and Data System: A Comprehensive Review. J Cardiovasc Imaging 2021; 30:1-24. [PMID: 34080334 PMCID: PMC8792723 DOI: 10.4250/jcvi.2020.0195] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 11/25/2022] Open
Abstract
The Coronary Artery Disease Reporting and Data System (CAD-RADS) is a standardized reporting method for coronary computed tomography angiography (CCTA). It summarizes the findings of CCTA in 6 categories ranging from CAD-RADS 0 (complete absence of coronary artery disease) to CAD-RADS 5 (total occlusion of at least one vessel). It is applied on per patient basis for the highest grade of the stenotic lesion. The CAD-RADS also provides category-specific treatment recommendations, helping patient management. The main objectives of the CAD-RADS are to improve the consistency in reporting, facilitate the communication between interpreting and referring clinicians, recommend the best course of patient management, and produce consistent data for quality improvement, research and education. However, CAD-RADS has many limitations, resulting into the misclassification of the observed findings, misinterpretation of the final category, and misguidance for the treatment based upon the single score. In this review, the authors discuss the CAD-RADS categories and modifiers, along with the strengths and limitations of this new classification system.
Collapse
Affiliation(s)
- Parveen Kumar
- Department of Radiodiagnosis & Imaging, Fortis Escort Heart Institute, New Delhi, India.
| | - Mona Bhatia
- Department of Radiodiagnosis & Imaging, Fortis Escort Heart Institute, New Delhi, India.,Cardiac Imaging, Cardiological Society of India, Kolkata, India.,International Regional Committee, India Chapter, Society of Cardiovascular Computed Tomography, Arlington, VA, USA
| |
Collapse
|
42
|
Jafari P, Goudarzi R, Amiresmaeili M, Rashidinejad H. The optimal diagnostic strategies for patient with coronary artery diseases and stable chest pain syndrome: a cost-effectiveness analysis. Egypt Heart J 2020; 72:82. [PMID: 33226507 PMCID: PMC7683761 DOI: 10.1186/s43044-020-00111-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Numerous invasive and noninvasive diagnostic tests with different cost and effectiveness exist for detection of coronary artery disease. This diversity leads to unnecessary utilization of health services. For this reason, this study focused on the cost-effectiveness analysis of diagnostic strategies for coronary artery disease from the perspective of the health care system with 1-year time horizon. Results Incremental cost effectiveness ratios of all strategies were less than the threshold except for the electrocardiography-computed tomography angiography-coronary angiography strategy, and cost of the cardiac magnetic resonance imaging-based strategy was higher than the cost of other strategies. Also, the number of correct diagnosis in the electrocardiography-coronary angiography strategy was higher than the other strategies, and its ICER was 15.197 dollars per additional correct diagnosis. Moreover, the sensitivity analysis found that the probability of doing MRI and sensitivity of the exercise electrocardiography had impact on the results. Conclusion The most cost-effective strategy for acute patient is ECG-CA strategy, and for chronic patient, the most cost-effective strategies are electrocardiography-single photon emission computed tomography-coronary angiography and electrocardiography-exercise electrocardiography-coronary angiography. Applying these strategies in the same clinical settings may lead to a better utilization of resources.
Collapse
Affiliation(s)
- Parvin Jafari
- Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Goudarzi
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammadreza Amiresmaeili
- Department of Health Management and Economics, Faculty of Management and Medical Informatics, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamidreza Rashidinejad
- Cardiovascular Research center,institute of basic and clinical physiology science., Kerman University of Medical Sciences, Kerman, Iran
| |
Collapse
|
43
|
Gul M, Sheikh M, Chaudhry A, Gerges L, Al Halabi H, Feldman E, Chaudhry A. Role of cardiac nuclear stress perfusion exam after computed tomographic coronary angiogram for evaluation of obstructive coronary artery disease in patients with chest pain. J Thorac Dis 2020; 12:5067-5077. [PMID: 33145083 PMCID: PMC7578483 DOI: 10.21037/jtd-2019-pitd-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Clinical workup for chest pain varies among institutions. Acute coronary syndrome (ACS) is the primary diagnosis to rule out in the differential diagnosis, due to its associated mortality and morbidity. Although studies have demonstrated efficacy of coronary computed tomographic angiography (CCTA) in diagnosis obstructive coronary artery disease (CAD), there is limited evidence in the clinical value of performing cardiac nuclear stress perfusion imaging [myocardial perfusion imaging (MPI)] exam in patients with chest pain after undergoing CCTA. We aim to evaluate clinical value of follow-up nuclear cardiac MPI in patients with chest pain who have undergone recent CCTA. Methods A total of 1,000 patients were evaluated in this IRB approved retrospective study who presented with symptoms of ACS. Patients who had elevated troponin or abnormal electrocardiogram (ECG) findings at initial presentation or prior to cardiac nuclear MPI were excluded from the study. All patients who underwent 64- or 320-detector row ECG-gated CCTA as well as a follow-up nuclear MPI. Patients who had diagnostics studies limited by artifact [e.g., suboptimal intravenous (IV) contrast bolus in CCTA, motion artifact on CCTA or MPI, etc.] were excluded. Results One hundred patients met the inclusion criteria. Patient demographics include average age 64.3 [32–89] years, 59 male, 41 females. Ninety-five/100 patients had at least one vessel with 50–70% coronary artery diameter stenosis measured on CCTA. There were no focal perfusion abnormalities identified on cardiac nuclear MPI in patients with less than 70% stenosis diagnosed on CCTA. Five percent of patients were identified with coronary arterial narrowing greater than 70% on CCTA and all 5 of these patients have evidence of abnormal cardiac nuclear stress test (perfusion abnormalities, chest pain, abnormal ECG). Conclusions In low-to-intermediate risk patients with chest pain and evidence of non-critical coronary artery stenosis (i.e., less than 70% stenosis) diagnosed on CCTA, a follow-up cardiac nuclear perfusion imaging is of limited value.
Collapse
Affiliation(s)
- Maryam Gul
- Precision Rheumatology, Anaheim, CA, USA
| | - Mubashir Sheikh
- Department of Diagnostic and Interventional Radiology, City of Hope National Medical Center, Duarte, CA, USA
| | - Abbas Chaudhry
- Department of Diagnostic and Interventional Radiology, City of Hope National Medical Center, Duarte, CA, USA
| | - Luke Gerges
- Department of Diagnostic and Interventional Radiology, City of Hope National Medical Center, Duarte, CA, USA
| | - Hadi Al Halabi
- Department of Diagnostic and Interventional Radiology, City of Hope National Medical Center, Duarte, CA, USA
| | - Eric Feldman
- Department of Diagnostic and Interventional Radiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Ammar Chaudhry
- Department of Diagnostic and Interventional Radiology, Stony Brook University Medical Center, Stony Brook, NY, USA
| |
Collapse
|
44
|
Seitun S, Clemente A, Maffei E, Toia P, La Grutta L, Cademartiri F. Prognostic value of cardiac CT. Radiol Med 2020; 125:1135-1147. [PMID: 33047297 DOI: 10.1007/s11547-020-01285-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
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.
Collapse
Affiliation(s)
- Sara Seitun
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Genoa, Italy
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa, Italy
| | - Erica Maffei
- Department of Radiology - Area Vasta 1 - ASUR Marche, Ospedale Civile "Santa Maria della Misericordia" di Urbino, Viale Federico Comandino, 70, 61029, Urbino, PU, Italy
| | - Patrizia Toia
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
| | | | | |
Collapse
|
45
|
Chow BJW, Coyle D, Hossain A, Laine M, Hanninen H, Ukkonen H, Rajda M, Larose E, Hartikainen J, Mielniczuk L, Kass M, Connelly KA, O'Meara E, Garrard L, Bishop H, Small G, Hedman M, Coyle K, Yla-Herttuala S, Knuuti J, Wells GA, Beanlands RS. Computed tomography coronary angiography for patients with heart failure (CTA-HF): a randomized controlled trial (IMAGE-HF 1C). Eur Heart J Cardiovasc Imaging 2020; 22:1083-1090. [PMID: 32588042 DOI: 10.1093/ehjci/jeaa109] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 02/24/2020] [Indexed: 01/13/2023] Open
Abstract
AIMS This randomized controlled trial sought to determine the financial impact of an initial diagnostic strategy of coronary computed tomography angiography (CCTA) in patients with heart failure (HF) of unknown aetiology. Invasive coronary angiography (ICA) is used to investigate HF patients. CCTA may be a non-invasive cost-effective alternative to ICA. This randomized controlled trial sought to determine the financial impact of an initial diagnostic strategy of coronary computed tomography angiography (CCTA) in patients with heart failure (HF) of unknown aetiology. METHODS AND RESULTS This multicentre, international trial enrolled patients with HF of unknown aetiology. The primary outcome was the cost of CCTA vs. ICA strategies at 12 months. Clinical outcomes were also collected. An 'intention-to-diagnose' analysis was performed and a secondary 'as-tested' analysis was based on the modality received. Two hundred and forty-six patients were randomized (age = 57.8 ± 11.0 years, ejection fraction = 30.1 ± 10.1%). The severity of coronary artery disease was similar in both groups. In the 121 CCTA patients, 93 avoided ICA. Rates of downstream ischaemia and viability testing were similar for both arms. There were no significant differences in the composite clinical outcomes or quality of life measures. The cost of CCTA trended lower than ICA [CDN -$871 (confidence interval, CI -$4116 to $3028)]. Using an 'as-tested' analysis, CCTA was associated with a decrease in healthcare costs (CDN -$2932, 95% CI -$6248 to $746). CONCLUSION In patients with HF of unknown aetiology, costs were not statistically different between the CCTA and ICA strategies. CLINICAL TRIALS.GOV NCT01283659.
Collapse
Affiliation(s)
- Benjamin J W Chow
- Department of Medicine (Cardiology), The University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada.,Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Alomgir Hossain
- Department of Medicine (Cardiology), The University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Mika Laine
- Helsinki University Central Hospital, Helsinki, Finland
| | | | - Heikki Ukkonen
- Heart Centre and Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | | | | | | | - Lisa Mielniczuk
- Department of Medicine (Cardiology), The University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada
| | - Malek Kass
- University of Manitoba, Winnipeg, Canada
| | - Kim A Connelly
- Department of Cardiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Eileen O'Meara
- Montréal Heart Institute, Université de Montréal, Montréal, Canada
| | - Linda Garrard
- Department of Medicine (Cardiology), The University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada
| | | | - Gary Small
- Department of Medicine (Cardiology), The University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada.,Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Marja Hedman
- Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Kathryn Coyle
- Health Economics Research Group, Institute of Environment, Health and Societies, Brunel University London, London, UK
| | | | - Juhani Knuuti
- Heart Centre and Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Rob S Beanlands
- Department of Medicine (Cardiology), The University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON K1Y 4W7, Canada.,Department of Radiology, University of Ottawa, Ottawa, Canada
| | | |
Collapse
|
46
|
Ngam PI, Ong CC, Chai P, Wong SS, Liang CR, Teo LLS. Computed tomography coronary angiography - past, present and future. Singapore Med J 2020; 61:109-115. [PMID: 32488269 DOI: 10.11622/smedj.2020028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Computed tomography coronary angiography (CTCA) is a robust and reliable non-invasive alternative imaging modality to invasive coronary angiography, which is the reference standard in evaluating the degree of coronary artery stenosis. CTCA has high negative predictive value and can confidently exclude significant coronary artery disease (CAD) in low to intermediate risk patients. Over the years, substantial effort has been made to reduce the radiation dose and increase the cost efficiency of CTCA. In this review, we present the evolution of computed tomography scanners in the context of coronary artery imaging as well as its clinical applications and limitations. We also highlight the future directions of CTCA as a one-stop non-invasive imaging modality for anatomic and functional assessment of CAD.
Collapse
Affiliation(s)
- Pei Ing Ngam
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Ching Ching Ong
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Siong Sung Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Chong Ri Liang
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Lynette Li San Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore
| |
Collapse
|
47
|
Nieman K. The feasibility, findings and future of CT-FFR in the emergency ward. J Cardiovasc Comput Tomogr 2020; 14:287-288. [DOI: 10.1016/j.jcct.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
|
48
|
Canan A, Ranganath P, Goerne H, Abbara S, Landeras L, Rajiah P. CAD-RADS: Pushing the Limits. Radiographics 2020; 40:629-652. [PMID: 32281902 DOI: 10.1148/rg.2020190164] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coronary CT angiography is now established as the first-line diagnostic imaging test to exclude coronary artery disease (CAD) in the population at low to intermediate risk. Wide variability exists in both the reporting of coronary CT angiography and the interpretation of these reports by referring physicians. The CAD Reporting and Data System (CAD-RADS) is sponsored by multiple societies and is a collaborative effort to provide standard classification of CAD, which is then integrated into patient clinical care. The main goals of the CAD-RADS are to decrease variability among readers; enhance communication between interpreting and referring clinicians, allowing collaborative determination of the best course of patient care; and generate consistent data for auditing, data mining, quality improvement, research, and education. There are several scenarios in which the CAD-RADS guidelines are ambiguous or do not provide definite recommendations for further management of CAD. The authors discuss the CAD-RADS categories and modifiers, highlight a variety of complex or ambiguous scenarios, and provide recommendations for managing these scenarios. Online supplemental material is available for this article. ©RSNA, 2020 See discussion on this article by Aviram and Wolak.
Collapse
Affiliation(s)
- Arzu Canan
- From the Department of Radiology, Division of Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Tex (A.C., P. Ranganath, H.G., S.A., P. Rajiah); Imaging and Diagnosis Center, Guadalajara, Mexico (H.G.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (L.L.)
| | - Praveen Ranganath
- From the Department of Radiology, Division of Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Tex (A.C., P. Ranganath, H.G., S.A., P. Rajiah); Imaging and Diagnosis Center, Guadalajara, Mexico (H.G.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (L.L.)
| | - Harold Goerne
- From the Department of Radiology, Division of Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Tex (A.C., P. Ranganath, H.G., S.A., P. Rajiah); Imaging and Diagnosis Center, Guadalajara, Mexico (H.G.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (L.L.)
| | - Suhny Abbara
- From the Department of Radiology, Division of Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Tex (A.C., P. Ranganath, H.G., S.A., P. Rajiah); Imaging and Diagnosis Center, Guadalajara, Mexico (H.G.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (L.L.)
| | - Luis Landeras
- From the Department of Radiology, Division of Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Tex (A.C., P. Ranganath, H.G., S.A., P. Rajiah); Imaging and Diagnosis Center, Guadalajara, Mexico (H.G.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (L.L.)
| | - Prabhakar Rajiah
- From the Department of Radiology, Division of Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, Tex (A.C., P. Ranganath, H.G., S.A., P. Rajiah); Imaging and Diagnosis Center, Guadalajara, Mexico (H.G.); and Department of Radiology, University of Chicago Medical Center, Chicago, Ill (L.L.)
| |
Collapse
|
49
|
Madaj P, Li D, Nakanishi R, Andreini D, Pontone G, Conte E, O’Rourke Franzcr R, Hamilton-Craig C, Nimmagadda M, Kim N, Fatima B, Dailing C, Budoff MJ. Lower Radiation Dosing in Cardiac CT Angiography: The CONVERGE Registry. J Nucl Med Technol 2020; 48:58-62. [DOI: 10.2967/jnmt.119.229500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/05/2019] [Indexed: 11/16/2022] Open
|
50
|
Siddiqui WJ, Rawala MS, Abid W, Zain M, Sadaf MI, Abbasi D, Alvarez C, Mansoor F, Hasni SF, Aggarwal S. Is Physiologic Stress Test with Imaging Comparable to Anatomic Examination of Coronary Arteries by Coronary Computed Tomography Angiography to Investigate Coronary Artery Disease? - A Systematic Review and Meta-Analysis. Cureus 2020; 12:e6941. [PMID: 32190493 PMCID: PMC7067363 DOI: 10.7759/cureus.6941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective Coronary computed tomography angiography (CCTA) is a noninvasive diagnostic modality that remains underutilized compared to functional stress testing (ST) for investigating coronary artery disease (CAD). Several patients are misdiagnosed with noncardiac chest pain (CP) that eventually die from a cardiovascular event in subsequent years. We compared CCTA to ST to investigate CP. Methods We searched MEDLINE, PubMed, Cochrane Library, and Embase from January 1, 2007 to July 1, 2018 for randomized controlled trials (RCTs) comparing CCTA to ST in patients who presented with acute or stable CP. We used Review Manager (RevMan) [Computer program] Version 5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) for review and analysis. Results We included 16 RCTs enrolling 21,210 patients; there were more patients with hyperlipidemia and older patients in the ST arm compared to the CCTA arm. There was no difference in mortality: 103 in the CCTA arm vs. 110 in the ST arm (risk ratio [RR] = 0.93, 95% confidence interval [CI] = 0.71-1.21, P = .58, and I2 = 0%). A significant reduction was seen in myocardial infarctions (MIs) after CCTA compared to ST: 115 vs. 156 (RR = 0.71, CI = 0.56-0.91, P < .006, I2=0%). On subgroup analysis, the CCTA arm had fewer MIs vs. the ST with imaging subgroup (RR = 0.70, CI = 0.54-0.89, P = .004, I2 = 0%) and stable CP subgroup (RR = 0.66, CI = 0.50-0.88, P = .004, I2 = 0%). The CCTA arm showed significantly higher invasive coronary angiograms and revascularizations and significantly reduced follow-up testing and recurrent hospital visits. A trend towards increased unstable anginas was seen in the CCTA arm. Conclusions Our analysis showed a significant reduction in downstream MIs, hospital visits, and follow-up testing when CCTA is used to investigate CAD with no difference in mortality.
Collapse
Affiliation(s)
- Waqas J Siddiqui
- Cardiology/Nephrology, Drexel University College of Medicine, Philadelphia, USA
| | | | - Waqas Abid
- Interventional Radiology, Christiana Hospital, Newark, USA
| | - Muhammad Zain
- Internal Medicine, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, PAK
| | | | - Danish Abbasi
- Cardiovascular Diseases, University of Arkansas, Little Rock, USA
| | | | | | - Syed Farhan Hasni
- Heart Failure and Transplant, Albert Einstein Hospital, Philadelphia, USA
| | | |
Collapse
|