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Doughty A, Keane G, Wadley AJ, Mahoney B, Bueno AA, Coles SJ. Plasma concentrations of thioredoxin, thioredoxin reductase and peroxiredoxin-4 can identify high risk patients and predict outcome in patients with acute coronary syndrome: A clinical observation. Int J Cardiol 2024; 403:131888. [PMID: 38382848 DOI: 10.1016/j.ijcard.2024.131888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/18/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Oxidative stress is a pathological feature of acute coronary syndrome (ACS), a complex disease with varying clinical outcomes. Surrogate biomarkers of oxidative stress including, peroxiredoxin-2 (PRDX2), PRDX4, thioredoxin (TRX) and thioredoxin reductase (TRXR) were measured in ACS patients at presentation and follow-up, to assess their clinical utility in diagnosis and risk stratification. METHODS Plasma from 145 participants (80 ACS and 65 healthy) at diagnosis, 1-3 month (first) and 6-month follow-up (second) was analysed by ELISA. ACS patients were monitored for 12-months. RESULTS ACS patients at diagnosis had significantly higher concentrations of TRX (p < 0.05), TRXR (p < 0.01) and PRDX4 (p < 0.01), compared to healthy donors. This was increase was driven by non-ST elevated myocardial infarction for TRX (p < 0.01) and PRDX4 (p < 0.05). For TRXR, ACS females were significantly higher than males (p < 0.05). TRX was also higher in older females (>55 years) at diagnosis (p < 0.05). At first follow-up, TRX had lowered, whereas PRDX4 remained significantly high (p < 0.05). Stratification of ACS patients according to percutaneous coronary intervention (PCI) revealed that TRXR was significantly higher in patients receiving PCI to the right coronary artery (p < 0.05). Whereas both TRXR (p < 0.01) and PRDX4 (p < 0.01) were significantly higher in patients receiving PCI to the left anterior descending (LAD) artery. ACS patients who had plasma TRX >13.40 ng/ml at second follow-up were at high risk of readmission (p < 0.05), as were patients with TRXR of <1000 pg/ml at diagnosis having PCI to the LAD (p < 0.05). CONCLUSION This study indicates that TRX, TRXR and PRDX4 may have clinical utility for ACS stratification.
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Affiliation(s)
- Angela Doughty
- Department of Cardiology, Worcester Acute Hospitals NHS Trust, Worcester, WR5 1DD, UK
| | - Gary Keane
- School of Science & the Environment, University of Worcester, WR2 6AJ, UK
| | - Alex J Wadley
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, B15 2TT, UK
| | - Berenice Mahoney
- Three Counties Medical School, University of Worcester, WR2 6AJ, UK
| | - Allain A Bueno
- School of Science & the Environment, University of Worcester, WR2 6AJ, UK
| | - Steven J Coles
- School of Science & the Environment, University of Worcester, WR2 6AJ, UK.
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Andrade LFD, Souza AC, Peclat T, Bartholo C, Pavanelo T, Lima RDSL. The Prognostic Value and Clinical Use of Myocardial Perfusion Scintigraphy in Asymptomatic Patients after Percutaneous Coronary Intervention. Arq Bras Cardiol 2018; 111:784-793. [PMID: 30517374 PMCID: PMC6263458 DOI: 10.5935/abc.20180199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/02/2018] [Indexed: 01/18/2023] Open
Abstract
Background The role of myocardial perfusion scintigraphy (MPS) in the follow-up of
asymptomatic patients after percutaneous coronary intervention (PCI) is not
established. Objectives To evaluate the prognostic value and clinical use of MPS in asymptomatic
patients after PCI. Methods Patients who underwent MPS consecutively between 2008 and 2012 after PCI were
selected. The MPS were classified as normal and abnormal, the perfusion
scores, summed stress score (SSS), and summed difference score (SDS) were
calculated and converted into percentage of total perfusion defect and
ischemic defect. The follow-up was undertaken through telephone interviews
and consultation with the Mortality Information System. Primary endpoints
were death, cardiovascular death, and nonfatal acute myocardial infarction
(AMI), and secondary endpoint was revascularization. Logistic regression and
COX method were used to identify the predictors of events, and the value of
p < 0.05 was considered statistically significant. Results A total of 647 patients were followed for 5.2 ± 1.6 years. 47% of MPS
were normal, 30% were abnormal with ischemia, and 23% were abnormal without
ischemia. There were 61 deaths, 27 being cardiovascular, 19 non-fatal AMI,
and 139 revascularizations. The annual death rate was higher in those with
abnormal perfusion without ischemia compared to the groups with ischemia and
normal perfusion (3.3% × 2% × 1.2%, p = 0.021). The annual
revascularization rate was 10.3% in the ischemia group, 3.7% in those with
normal MPS, and 3% in those with abnormal MPS without ischemia. The
independent predictors of mortality and revascularization were,
respectively, total perfusion defect greater than 6%, and ischemic defect
greater than 3%. Forty-two percent of the patients underwent MPS less than 2
years after PCI, and no significant differences were observed in relation to
those who underwent it after that period. Conclusion Although this information is not contemplated in guidelines, in this study
MPS was able to predict events in asymptomatic after PCI patients,
regardless of when they were performed.
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Affiliation(s)
- Larissa Franco de Andrade
- Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil.,Clínica de Diagnóstico por Imagem, Rio de Janeiro, RJ - Brazil
| | - Ana Carolina Souza
- Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
| | - Thais Peclat
- Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
| | - Caio Bartholo
- Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
| | - Thalita Pavanelo
- Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil
| | - Ronaldo de Souza Leão Lima
- Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brazil.,Clínica de Diagnóstico por Imagem, Rio de Janeiro, RJ - Brazil
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Randomized comparison between provisional and routine kissing-balloon technique after main vessel crossover stenting for coronary bifurcation lesions. Heart Vessels 2017; 32:1067-1076. [PMID: 28401352 DOI: 10.1007/s00380-017-0977-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 04/07/2017] [Indexed: 12/13/2022]
Abstract
We compared the myocardial ischemic burden of provisional and routine final kissing-balloon inflation (FKI) with the 1-stent strategy using a second-generation drug-eluting stent for coronary bifurcation lesions (CBL). There are no established guidelines for side branch (SB) intervention after main vessel stenting. In total, 113 CBL patients were randomized to receive different SB intervention strategies: provisional-FKI group (n = 57; FKI only when SB flow was TIMI <3) and routine-FKI group (n = 56; mandatory FKI with aggressive treatment until SB-residual stenosis <50%). Dipyridamole-stress myocardial perfusion scintigraphy with 99mTc was performed after 8 months. The regional summed-difference score (r-SDS) was calculated according to the coronary territory. The primary endpoint included target vessel ischemia (TVI; r-SDS ≥ 2) at 8 months, whereas the clinical primary endpoint was major adverse cardiovascular events (MACE) at 3 years. The percent (%) myocardial ischemia (100 × SDS/68) was also calculated. At 8 months, TVI was identified in 11 and 4% in the provisional-FKI and routine-FKI groups, respectively (p = 0.226). SB-binary restenosis (48 vs. 4%, p < 0.001) and myocardial ischemia at the SB territory (11 vs. 0%, p = 0.030) were more common in the provisional-FKI group; however, in TVI patients, % myocardial ischemia (4.12 ± 1.23% vs. 3.68 ± 1.04%; p = 0.677) did not significantly differ. Moderate/severe ischemia (>10% myocardial ischemia) was not observed in the target vessel in either group. Long-term cumulative MACE were similar between the groups (9 vs. 14%; p = 0.358). Provisional-FKI according to TIMI-SB flow grade led to similar and acceptable myocardial ischemia, in comparison with routine-FKI, which may contribute to the identical long-term follow-up.
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5
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Lee G, Twerenbold R, Tanglay Y, Reichlin T, Honegger U, Wagener M, Jaeger C, Rubini Gimenez M, Hochgruber T, Puelacher C, Radosavac M, Kreutzinger P, Stallone F, Hillinger P, Krivoshei L, Herrmann T, Mayr R, Freese M, Wild D, Rentsch KM, Todd J, Osswald S, Zellweger MJ, Mueller C. Clinical benefit of high-sensitivity cardiac troponin I in the detection of exercise-induced myocardial ischemia. Am Heart J 2016; 173:8-17. [PMID: 26920591 DOI: 10.1016/j.ahj.2015.11.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/14/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND A pilot study using a novel high-sensitivity cardiac troponin I (hs-cTnI) assay suggested that cTnI might be released into blood during exercise-induced myocardial ischemia. We investigated the potential clinical value of this signal. METHODS We included 819 patients with suspected exercise-induced myocardial ischemia referred for rest/bicycle myocardial perfusion single-photon emission computed tomography. The treating cardiologist used all available clinical information to quantify clinical judgment regarding the presence of myocardial ischemia using a visual analog scale twice: prior and after stress testing. High-sensitivity cTnI measurements were obtained before, immediately after peak stress, and 2 hours after stress testing in a blinded manner. Myocardial ischemia was adjudicated using perfusion single-photon emission computed tomography and coronary angiography findings. RESULTS Exercise-induced myocardial ischemia was detected in 278 (34%) patients. High-sensitivity cTnI levels were significantly higher at all time points in patients with myocardial ischemia as compared with those without (P < .001 for all). Combining clinical judgment prior exercise testing with baseline hs-cTnI levels increased diagnostic accuracy as quantified by the area under the receiver operating characteristics curve (AUC) from 0.672 to 0.757 (P < .001). Combining clinical judgment after exercise testing (AUC 0.704) with baseline or poststress hs-cTnI levels also increased the diagnostic accuracy (AUC 0.761-0.771, P < .001 for all). In contrast, exercise-induced changes in hs-cTnI during exercise did not seem useful, as they were small and similar in patients with or without myocardial ischemia. CONCLUSIONS High-sensitivity cTnI concentrations at rest and after exercise, but not its exercise-induced changes, provide substantial incremental value to clinical judgment including exercise electrocardiography regarding the presence of myocardial ischemia.
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6
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Buechel RR, Kaufmann BA, Tobler D, Wild D, Zellweger MJ. Non-invasive nuclear myocardial perfusion imaging improves the diagnostic yield of invasive coronary angiography. Eur Heart J Cardiovasc Imaging 2015; 16:842-7. [PMID: 25914037 DOI: 10.1093/ehjci/jev095] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/19/2015] [Indexed: 01/11/2023] Open
Abstract
AIMS Several studies reported on the moderate diagnostic yield of elective invasive coronary angiography (ICA) regarding the presence of coronary artery disease (CAD), but limited data are available on how prior testing for ischaemia may contribute to improve the diagnostic yield in an every-day clinical setting. This study aimed to assess the value and use of cardiac myocardial perfusion single photon emission computed tomography (MPS) in patient selection prior to elective ICA. METHODS AND RESULTS The rate of MPS within 90 days prior to elective ICA was assessed and the non-invasive test results were correlated with the presence of obstructive CAD on ICA (defined as stenosis of ≥50% of a major epicardial coronary vessel). Multivariate logistic regression analysis was performed to identify predictors of obstructive CAD. A total of 7530 consecutive patients were included. At catheterization, 3819 (50.7%) were diagnosed as having obstructive CAD. Patients with a positive result on MPS (performed in 23.5% of patients) were significantly more likely to have obstructive CAD as assessed by ICA than those who did not undergo non-invasive testing (74.4 vs. 45.6%, P < 0.001). Furthermore, a pathological MPS result was a strong, independent predictor for CAD findings among traditional risk factors and symptoms. CONCLUSION In an every-day clinical setting, the use of MPS substantially increases the diagnostic yield of elective ICA and provides incremental value over clinical risk factors and symptoms in predicting obstructive CAD, thus emphasizing its importance in the decision-making process leading to the use of diagnostic catheterization.
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Affiliation(s)
- Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Switzerland
| | - Daniel Tobler
- Department of Cardiology, University Hospital Basel, Switzerland
| | - Damian Wild
- Department of Radiology, Division of Nuclear Medicine, University Hospital Basel, Switzerland
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7
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Rossini R, Oltrona Visconti L, Musumeci G, Filippi A, Pedretti R, Lettieri C, Buffoli F, Campana M, Capodanno D, Castiglioni B, Cattaneo MG, Colombo P, De Luca L, De Servi S, Ferlini M, Limbruno U, Nassiacos D, Piccaluga E, Raisaro A, Ravizza P, Senni M, Tabaglio E, Tarantini G, Trabattoni D, Zadra A, Riccio C, Bedogni F, Febo O, Brignoli O, Ceravolo R, Sardella G, Bongo S, Faggiano P, Cricelli C, Greco C, Gulizia MM, Berti S, Bovenzi F. A multidisciplinary consensus document on follow-up strategies for patients treated with percutaneous coronary intervention. Catheter Cardiovasc Interv 2014; 85:E129-39. [DOI: 10.1002/ccd.25724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 11/03/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Roberta Rossini
- Dipartimento Cardiovascolare; AO Papa Giovanni XXIII; Bergamo Italia
| | | | - Giuseppe Musumeci
- Dipartimento Cardiovascolare; AO Papa Giovanni XXIII; Bergamo Italia
| | | | - Roberto Pedretti
- UO di Cardiologia Riabilitativa, IRCCS Fondazione Salvatore Maugeri; Istituto Scientifico di Tradate; Tradate Italia
| | - Corrado Lettieri
- UO di Cardiologia; Azienda Ospedaliera Carlo Poma; Mantova Italia
| | | | - Marco Campana
- UO Cardiologia, Fondazione Poliambulanza; Brescia Italia
| | - Davide Capodanno
- Dipartimento di Cardiologia; Ospedale Ferrarotto, Università di Catania; Catania Italia
| | | | | | - Paola Colombo
- Dipartimento Cardiotoracovascolare; Ospedale Niguarda; Milano Italia
| | - Leonardo De Luca
- Department of Cardiovascular Sciences; European Hospital; Roma Italia
| | - Stefano De Servi
- Unita' Coronarica; IRCCS Fondazione Policlinico San Matteo; Pavia Italia
| | - Marco Ferlini
- Divisione di Cardiologia; IRCCS Fondazione Policlinico S. Matteo; Pavia Italia
| | - Ugo Limbruno
- Divisione di Cardiologia; Ospedale della Misericordia; Grosseto Italia
| | | | | | - Arturo Raisaro
- Divisione di Cardiologia; IRCCS Fondazione Policlinico S. Matteo; Pavia Italia
| | | | - Michele Senni
- Dipartimento Cardiovascolare; AO Papa Giovanni XXIII; Bergamo Italia
| | | | - Giuseppe Tarantini
- Dipartimento di Scienze Cardiache; Toraciche e Vascolari, Università di Padova; Padova Italia
| | - Daniela Trabattoni
- Dipartimento di Scienze Cardiovascolari; Centro Cardiologico Monzino, IRCCS; Milano Italia
| | | | - Carmine Riccio
- UOC Cardiologia e Riabilitazione Cardiologica, Azienda Ospedaliera Sant'Anna e San Sebastiano; Caserta Italia
| | - Francesco Bedogni
- Department of Cardiology; Istituto Clinico S. Ambrogio; Milano Italia
| | - Oreste Febo
- UO Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS Istituto Scientifico di Montescano (PV); Pavia Italia
| | | | - Roberto Ceravolo
- Dipartimento di Cardiologia, Ospedale Civile Pugliese; Catanzaro Italia
| | - Gennaro Sardella
- Department of Cardiovascular; Respiratory and Morphologic Sciences, Policlinico Umberto I, “Sapienza” University of Rome; Italia
| | - Sante Bongo
- Divisione di Cardiologia; Azienda Ospedaliero Universitaria Maggiore della Carità; Novara Italia
| | | | | | - Cesare Greco
- UOC Cardiologia - Azienda ospedaliera San Giovanni Addolorata Roma; Italia
| | - Michele Massimo Gulizia
- UOC Cardiologia; Azienda Rilievo Nazionale e Alta Specializzazione, Ospedale Garibaldi-Nesima; Catania Italia
| | - Sergio Berti
- Operative Unit of Cardiology, G. Pasquinucci Heart Hospital, Fondazione Toscana G. Monasterio; Massa Italia
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8
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Xu N, Zhang J, Li M, Pan J, Lu Z. Incidence and classification of neointimal proliferation and in-stent restenosis in post-stenting patients at 1-year interval: findings from non-invasive coronary computed tomography angiography. Eur J Radiol 2014; 83:1816-21. [PMID: 25112673 DOI: 10.1016/j.ejrad.2014.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 07/15/2014] [Accepted: 07/21/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To evaluate the incidence of coronary in-stent restenosis (ISR) and neointimal proliferation by coronary CT angiography (CCTA) at 1-year follow-up in asymptomatic patients. METHODS 234 patients (mean age: 67 ± 10.2 years, range 39-88 years, 180 males and 54 females) with 379 stents were prospectively enrolled in this study. Binary ISR was classified by CCTA into 4 types using Mehran classification. Neointimal proliferation was similarly classified into focal and diffuse types. All patients with CCTA-revealed ISR or neointimal proliferation underwent further invasive coronary angiography (ICA) for validation. Fisher's exact test was used for comparison. RESULTS ICA revealed patent stents with neointimal proliferation in 39 patients (16.7%, 39/234) and binary ISR in 23 patients (9.8%, 23/234). Lesion-based analysis showed 12 type I ISR lesions, 4 type II ISR lesions, 1 type III ISR lesion and 7 type IV ISR lesions. Among cases with neointimal proliferation, 27 lesions were classified as focal type whereas 13 lesions were classified as diffuse type. Patients with diabetes mellitus were associated with higher incidence of CCTA-revealed neointimal proliferation (21/77 vs. 18/157, p=0.002) as well as ISR (12/77 vs. 11/157, p=0.038), compared to patients without diabetes. CCTA was found to have good diagnostic performance for neointimal proliferation and ISR detection as well as classification, with an overall accuracy of 84.4% (54/64). CONCLUSIONS Silent ISR as well as neointimal proliferation is not uncommon findings in asymptomatic post-stenting patients at 1-year interval, as revealed by CCTA. Patients with diabetes are prone to have higher incidence of neointimal proliferation.
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Affiliation(s)
- Nan Xu
- Department of Radiology, East Hospital, Tongji University School of Medicine, No. 150, Jimo Road, Shanghai 200120, China.
| | - Jiayin Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, China.
| | - Minghua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, China.
| | - Jingwei Pan
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, China.
| | - Zhigang Lu
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, China.
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9
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Gerbaud E, Cochet H, Bullier E, Ragot C, Gilbert SH, Douard H, Pucheu Y, Laurent F, Coste P, Bordenave L, Montaudon M. Peri-infarct ischaemia assessed by cardiovascular MRI: comparison with quantitative perfusion single photon emission CT imaging. Br J Radiol 2014; 87:20130774. [DOI: 10.1259/bjr.20130774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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10
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Prognostic Value of “Routine” Cardiac Stress Imaging 5 Years After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2014; 7:615-21. [DOI: 10.1016/j.jcin.2014.01.161] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 12/30/2013] [Accepted: 01/02/2014] [Indexed: 11/20/2022]
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Cremer P, Hachamovitch R. Assessing the prognostic implications of myocardial perfusion studies: identification of patients at risk vs patients who may benefit from intervention? Curr Cardiol Rep 2014; 16:472. [PMID: 24585113 DOI: 10.1007/s11886-014-0472-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Stress myocardial perfusion imaging (MPI) has a well-established role in improving risk stratification. Recent analyses, compared with older data, suggest that the yield of stress MPI has decreased. In part, this trend relates to testing patients with heterogeneous, but improved, risk factor modification. In this setting, positron emission tomography with myocardial flow reserve enhances risk stratification as it reflects the end result of atherosclerosis. Recent studies have also emphasized the clinical impact of incremental risk stratification by assessing net reclassification improvement (NRI). Previous retrospective studies have favored an ischemic threshold to select patients that benefit from revascularization, but this finding has not been corroborated in randomized trials. However, no large randomized trial has directly tested a strategy of revascularization for patients with at least a moderate amount of ischemia at risk. Unfortunately, even when faced with a significantly abnormal MPI result, subsequent action is too often absent.
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Affiliation(s)
- Paul Cremer
- Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5 9500 Euclid Avenue, Cleveland, OH, 44915, USA
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Harb SC, Marwick TH. Prognostic value of stress imaging after revascularization: a systematic review of stress echocardiography and stress nuclear imaging. Am Heart J 2014; 167:77-85. [PMID: 24332145 DOI: 10.1016/j.ahj.2013.07.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 07/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Risk assessment may be important in patients being considered for repeat revascularization after prior coronary intervention or surgery. We sought the prognostic value of radionuclide stress myocardial perfusion imaging or echocardiography among patients with previous revascularization. METHODS Studies on the outcomes of stress imaging tests after revascularization were selected from an electronic search if they reported the odds or hazard ratio (HR) of an abnormal stress test in the prediction of mortality (cardiac or total), hard cardiac events (cardiac death and myocardial infarction [MI]), total hard events (total mortality and MI]), or overall events (cardiac death, MI, and repeat revascularization). RESULTS In 29 studies (12,874 patients, 63 ± 3 years, 80% men), an abnormal test result was associated with hard cardiac events (HR 1.2, 95% CI 1.1-1.3), cardiac mortality (HR 5.8, 95% CI 0.8-10.8), total mortality (HR 2.2, 95% CI 1.3-3.1), total hard events(HR 2.4, 95% CI 1.4-3.3), and overall events (HR 1.2, 95% CI 1.1-1.3). The nature of the end point was not associated with differences in the prediction of events, but the type of revascularization showed a significant association with outcome, with percutaneous intervention portending a worse outcome. Age and the timing of the stress imaging postrevascularization were inversely associated with survival. Gender, length of follow-up after testing, symptom status, past infarction, and risk factor status did not explain interstudy heterogeneity. CONCLUSIONS In patients with previous revascularization, abnormal results at stress echocardiography or radionuclide myocardial perfusion imaging are predictive of subsequent events, with age, type of revascularization, and the timing of the stress imaging after revascularization being important sources of heterogeneity between studies.
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Schepis T, Benz K, Haldemann A, Kaufmann PA, Schmidhauser C, Frielingsdorf J. Prognostic value of stress-gated 99m-technetium SPECT myocardial perfusion imaging: risk stratification of patients with multivessel coronary artery disease and prior coronary revascularization. J Nucl Cardiol 2013; 20:755-62. [PMID: 23839243 DOI: 10.1007/s12350-013-9749-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 05/31/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study assessed the prognostic value of stress-gated 99mTc-sestamibi myocardial perfusion SPECT (MPS) in patients with multivessel coronary artery disease (CAD) and prior revascularization according to the presence and severity of ischemia. METHODS AND RESULTS We studied the outcome of 472 patients with multivessel CAD and prior revascularization (coronary angioplasty, 290 patients; bypass surgery, 182 patients), who underwent exercise or dipyridamole 99mTc-sestamibi MPS for evaluation of ischemia. Visual scoring of perfusion images used 20 segments and a 5-point scale. Gated post-stress EF was automatically calculated. Endpoints included hard events: cardiac death (CD) and nonfatal myocardial infarction (MI). During a mean follow-up of 3.0 ± 1.0 years, 37 hard events occurred, including CD in 15 (3%) and MI in 22 (5%) patients. In a risk-adjusted multivariable Cox model, a history of prior MI, diabetes, abnormal MPS, moderate-to-severe ischemia, and post-stress EF <35% were important predictors of cardiac events. Four-year risk-adjusted survival was 97.9% for normal MPS, 87.3% for abnormal MPS with ischemia, and 82.1% for moderate-to-severe ischemia. CONCLUSIONS Among patients with previous coronary revascularization, stress-gated 99mTc-sestamibi MPS provides prognostic information for the prediction of cardiac events. A normal perfusion scan confers an excellent prognosis and an exceedingly low hard event rate (<1%/year). The presence of moderate-to-severe ischemia or a post-stress EF <35% identifies patients at highest risk of subsequent cardiac events.
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Affiliation(s)
- Tiziano Schepis
- Clinic of Cardiology, Department of Internal Medicine, City Hospital Triemli, Zurich, Switzerland
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14
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Myocardial perfusion imaging after coronary revascularization: a clinical appraisal. Eur J Nucl Med Mol Imaging 2013; 40:1275-82. [PMID: 23604804 DOI: 10.1007/s00259-013-2417-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/26/2013] [Indexed: 01/09/2023]
Abstract
Revascularization procedures, including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), are performed in many patients with coronary artery disease. Despite the effectiveness of these procedures, different follow-up strategies need to be considered for the management of patients after revascularization. Stress myocardial perfusion single-photon emission computed tomography (MPS) is a suitable imaging method for the evaluation of patients who have undergone PCI or CABG, and it has been used in the follow-up of such patients. Radionuclide imaging is included in the follow-up strategies after PCI and CABG in patients with symptoms, but guidelines warn against routine testing of all asymptomatic patients after revascularization. After PCI, in the absence of symptoms, radionuclide imaging is recommended and indicated as appropriate after incomplete or suboptimal revascularization and in specific asymptomatic patient subsets. On the other hand, the value of MPS late after CABG in risk stratification has been demonstrated even in the absence of symptoms. Thus, given the adverse outcome associated with silent ischaemia, it can be speculated that all patients regardless of clinical status should undergo stress testing late after revascularization. Larger prospective studies are needed to assess whether stress MPS will have an impact on the outcome in asymptomatic patients after revascularization.
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Dagenais GR, Lu J, Faxon DP, Bogaty P, Adler D, Fuentes F, Escobedo J, Krishnaswami A, Slater J, Frye RL. Prognostic impact of the presence and absence of angina on mortality and cardiovascular outcomes in patients with type 2 diabetes and stable coronary artery disease: results from the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. J Am Coll Cardiol 2013; 61:702-11. [PMID: 23410541 DOI: 10.1016/j.jacc.2012.11.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/30/2012] [Accepted: 11/08/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this analysis was to assess in patients with type 2 diabetes and stable coronary artery disease (CAD) whether the risk of all-cause mortality and cardiovascular events varied according to the presence or absence of angina and angina equivalent symptoms. BACKGROUND Data on the prognostic value of symptoms in these patients are limited. METHODS Post-hoc analysis was performed in 2,364 patients with type 2 diabetes and documented CAD enrolled in the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial to determine the occurrence of death and composite of death, myocardial infarction, and stroke during a 5-year follow-up according to cardiac symptoms at baseline. RESULTS There were 1,434 patients with angina (A), 506 with angina equivalents (E), and 424 with neither of these (N). The cumulative death rates (total 316) were 12% in A, 14% in E, and 10% in N (p = 0.3), and cardiovascular composite rates (total 548) were 24% in A, 24% in E, and 21% in N (p = 0.5). Compared with N, the hazard ratios adjusted for confounders were not different for death in A (1.11; 99% CI: 0.81 to 1.53) and E (1.17; 99% CI: 0.81 to 1.68) or for cardiovascular events in A (1.17; 99% CI: 0.92 to 1.50) and E (1.11; 99% CI: 0.84 to 1.48). CONCLUSIONS Whatever their symptom status, patients with type 2 diabetes and stable CAD were at similar risk of cardiovascular events and death. These findings suggest that these patients may be similarly managed in terms of risk stratification and preventive therapies. (Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; NCT00006305).
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Affiliation(s)
- Gilles R Dagenais
- Quebec Heart and Lung University Institute, Quebec City, Quebec, Canada.
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Microalbuminuria predicts silent myocardial ischaemia in type 2 diabetes patients. Eur J Nucl Med Mol Imaging 2013; 40:548-57. [PMID: 23314258 DOI: 10.1007/s00259-012-2323-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 12/10/2012] [Indexed: 12/16/2022]
Abstract
PURPOSE Myocardial ischaemia is frequently silent in patients with type 2 diabetes. Although it has been proposed as a potential screening tool, the role of myocardial perfusion single photon emission computed tomography (MPS) has recently been questioned, due to the low prevalence of positive scans and the low rate of cardiac events. The aim of this study was to assess if pretest clinical variables can identify a subgroup of asymptomatic patients with type 2 diabetes at risk of silent myocardial ischaemia and a subsequent poor outcome METHODS This prospective study included 77 patients (50 men, mean age 63 ± 9 years) with type 2 diabetes and no known coronary artery disease (CAD) or angina pectoris who underwent gated MPS to screen for CAD between March 2006 and October 2008. MPS images were interpreted using a semiquantitative visual 20-segment model to define summed stress, rest and difference scores. Ischaemia was defined as a sum difference score (SDS) ≥2. Patients were followed-up (median 4.1 years, range 0.8 - 6.1 years) and cardiac hard events (cardiac death or nonfatal myocardial infarction) were recorded. RESULTS Silent ischaemia was detected in 25 of the 77 patients (32 %). Specifically, 10 patients (13 %) had mild ischaemia (SDS 2 to ≤4) and 15 patients (19 %) had severe ischaemia (SDS >4). In univariate binary logistic analysis, microalbuminuria was the only significant predictor of silent ischaemia on MPS (odds ratio 4.42, 95 % CI 1.27 - 15.40; P = 0.019). The overall accuracy of microalbuminuria for predicting silent ischaemia was 71.4 % and was 89.6 % for predicting severe ischaemia. Kaplan-Meier curves showed no significant group differences in 5-year cardiac event-free survival between patients with and those without microalbuminuria, or between patients with SDS ≥2 and those with SDS <2. In contrast, 5-year event-free survival was significantly lower in patients with SDS >4 than in patients with SDS ≤4: 55.6 % (95 % CI 39.0 - 72.2 %) vs. 94.5 % (95 % CI: 91.4 - 97.6 %), respectively (Breslow test, chi-square 20.9, P < 0.001). Median cardiac event-free survival was not observed in the whole group, while the 25th percentile of cardiac event-free survival was reached only in patients with SDS >4 (2.3 years). In univariate Cox regression analysis, SDS >4 predicted cardiac event-free survival (hazard ratio 12.87, 95 % CI 2.86 - 27.98; P = 0.001), while SDS ≥2 did not (hazard ratio 2.78, 95 % CI 0.62 - 12.46, P = 0.16). CONCLUSION In this group of patients with type 2 diabetes, microalbuminuria was the only predictor of silent ischaemia on MPS. Assessment of microalbuminuria should be routinely considered among the first risk stratification steps for CAD in patients with type 2 diabetes, even though severe ischaemia on MPS is a major predictor of cardiac event-free survival.
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Ahmed W, Schlett CL, Uthamalingam S, Truong QA, Koenig W, Rogers IS, Blankstein R, Nagurney JT, Tawakol A, Januzzi JL, Hoffmann U. Single resting hsTnT level predicts abnormal myocardial stress test in acute chest pain patients with normal initial standard troponin. JACC Cardiovasc Imaging 2013; 6:72-82. [PMID: 23328564 PMCID: PMC3734805 DOI: 10.1016/j.jcmg.2012.08.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 08/17/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The goal of this study was to determine the ability of a single, resting high-sensitivity troponin T (hsTnT) measurement to predict abnormal myocardial perfusion imaging (MPI) in patients presenting with acute chest pain to the emergency department (ED). BACKGROUND HsTnT assays precisely detect very low levels of troponin T, which may be a surrogate for the presence and extent of myocardial ischemia. METHODS We included all patients from the ROMICAT I (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial, an observational cohort study, who underwent both single-photon emission computed tomography (SPECT)-MPI stress testing and 64-slice computed tomography angiography (CTA) and in whom hsTnT measurements were available. We assessed the discriminatory value of hsTnT for abnormal SPECT-MPI and the association of reversible myocardial ischemia by SPECT-MPI and the extent of coronary atherosclerosis by CTA to hsTnT levels. RESULTS Of the 138 patients (mean age 54 ± 11 years, 46% male), 19 (13.7%) had abnormal SPECT-MPI. Median hsTnT levels were significantly different between patients with normal and abnormal SPECT-MPI (9.41 pg/ml [interquartile range (IQR): 5.73 to 19.20 pg/ml] vs. 4.89 pg/ml [IQR: 2.34 to 7.68 pg/ml], p = 0.001). Sensitivity of 80% and 90% to detect abnormal SPECT-MPI was reached at hsTnT levels as low as 5.73 and 4.26 pg/ml, respectively. Corresponding specificity was 62% and 46%, and negative predictive value was 96% and 96%, respectively. HsTnT levels had good discriminatory ability for prediction of abnormal SPECT-MPI (area under the curve: 0.739, 95% confidence interval: 0.609 to 0.868). Both reversible myocardial ischemia and the extent of coronary atherosclerosis (combined model r(2) = 0.19 with partial of r(2) = 0.12 and r(2) = 0.05, respectively) independently and incrementally predicted the measured hsTnT levels. CONCLUSIONS In patients with acute chest pain, myocardial perfusion abnormalities and coronary artery disease are predicted by resting hsTnT levels. Prospective evaluations are warranted to confirm whether resting hsTnT could serve as a powerful triage tool in chest pain patients in the ED before diagnostic testing and improve the effectiveness of patient management.
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Affiliation(s)
- Waleed Ahmed
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher L. Schlett
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shanmugam Uthamalingam
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quynh A. Truong
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Wolfgang Koenig
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ian S. Rogers
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ahmed Tawakol
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James L. Januzzi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Mahnken AH. CT Imaging of Coronary Stents: Past, Present, and Future. ISRN CARDIOLOGY 2012; 2012:139823. [PMID: 22997590 PMCID: PMC3446716 DOI: 10.5402/2012/139823] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 08/16/2012] [Indexed: 11/23/2022]
Abstract
Coronary stenting became a mainstay in coronary revascularization therapy. Despite tremendous advances in therapy, in-stent restenosis (ISR) remains a key problem after coronary stenting. Coronary CT angiography evolved as a valuable tool in the diagnostic workup of patients after coronary revascularization therapy. It has a negative predictive value in the range of 98% for ruling out significant ISR. As CT imaging of coronary stents depends on patient and stent characteristics, patient selection is crucial for success. Ideal candidates have stents with a diameter of 3 mm and more. Nevertheless, even with most recent CT scanners, about 8% of stents are not accessible mostly due to blooming or motion artifacts. While the diagnosis of ISR is currently based on the visual assessment of the stent lumen, functional information on the hemodynamic significance of in-stent stenosis became available with the most recent generation of dual source CT scanners. This paper provides a comprehensive overview on previous developments, current techniques, and clinical evidence for cardiac CT in patients with coronary artery stents.
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Affiliation(s)
- Andreas H Mahnken
- Department of Diagnostic and Interventional Radiology, University Hospital, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
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19
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Gosselin G, Teo KK, Tanguay JF, Gokhale R, Hartigan PM, Maron DJ, Gupta V, Mancini GBJ, Bates ER, Chaitman BR, Spertus JA, Kostuk WJ, Dada M, Sedlis SP, Berman DS, Shaw LJ, O'Rourke RA, Weintraub WS, Boden WE. Effectiveness of percutaneous coronary intervention in patients with silent myocardial ischemia (post hoc analysis of the COURAGE trial). Am J Cardiol 2012; 109:954-9. [PMID: 22445578 DOI: 10.1016/j.amjcard.2011.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 11/07/2011] [Accepted: 11/07/2011] [Indexed: 11/17/2022]
Abstract
Previous studies have suggested that percutaneous coronary intervention (PCI) decreases long-term mortality in patients with silent myocardial ischemia (SMI), but whether PCI specifically decreases mortality when added to intensive medical therapy is unknown. We performed a post hoc analysis of clinical outcomes in patients in the COURAGE trial based on the presence or absence of anginal symptoms at baseline. Asymptomatic patients were classified as having SMI by electrocardiographic ischemia at rest or reversible stress perfusion imaging (exercise-induced or pharmacologic). Study end points included the composite primary end point (death or myocardial infarction [MI]); individual end points of death, MI, and hospitalization for acute coronary syndrome; and need for revascularization. Of 2,280 patients 12% (n = 283) had SMI and 88% were symptomatic (n = 1,997). There were no between-group differences in age, gender, cardiac risk factors, previous MI or revascularization, extent of angiographic disease, or ischemia by electrocardiogram or imaging. Compared to symptomatic patients, those with SMI had fewer subsequent revascularizations (16% vs 27%, p <0.001) regardless of treatment assignment and fewer hospitalizations for acute coronary syndrome (7% vs 12%, p <0.04). No significant differences in outcomes were observed between the 2 treatment groups, although there was a trend toward fewer deaths in the PCI group (n = 7, 5%) compared to the optimal medical therapy (OMT) group (n = 16, 11%, p = 0.12). In conclusion, addition of PCI to OMT did not decrease nonfatal cardiac events in patients with SMI but showed a trend toward fewer deaths. Although underpowered, given similar outcomes in other small studies, these findings suggest the need for an adequately powered trial of revascularization versus OMT in SMI patients.
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Conti CR, Bavry AA, Petersen JW. Silent ischemia: clinical relevance. J Am Coll Cardiol 2012; 59:435-41. [PMID: 22281245 DOI: 10.1016/j.jacc.2011.07.050] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 07/11/2011] [Accepted: 07/18/2011] [Indexed: 02/07/2023]
Abstract
Myocardial ischemia can occur without overt symptoms. In fact, asymptomatic (or silent) ST-segment depression during ambulatory electrocardiogram monitoring occurs more often than symptomatic ST-segment depression in patients with coronary artery disease. Initial studies documented that silent ischemia provided independent prediction of adverse outcomes in patients with known and unknown coronary artery disease. The ACIP (Asymptomatic Cardiac Ischemia Pilot Study) enrolled patients in the 1990s and found that revascularization was better than medical therapy in reducing silent ischemic episodes and possibly cardiovascular (CV) events. However, the more recent COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial found similar CV event rates between patients treated with optimal medical therapy alone and those treated with optimal medical therapy plus percutaneous revascularization. Therefore, in the current era, medical therapy appears to be as effective as revascularization in suppressing symptomatic ischemia and preventing CV events. COURAGE was not designed to evaluate changes in the frequency of silent ischemia. Therefore, silent ischemia may persist despite current-era treatment and might still identify patients with increased risk of CV events. Also, silent ischemia is likely to occur frequently in heart transplant patients with denervated hearts and coronary allograft vasculopathy, and future study aimed at improving the management of silent ischemia in this population is warranted. Additionally, future research is warranted to study the effect of newer medical therapies such as ranolazine or selected use of revascularization (for example, guided by fractional flow reserve) in those patients with persistent silent ischemia despite optimal current-era medical therapy.
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Affiliation(s)
- C Richard Conti
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida 32610, USA
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Diagnostic value of myocardial SPECT to detect in-stent restenosis after drug-eluting stent implantation. Int J Cardiovasc Imaging 2012; 28:2125-34. [PMID: 22395666 DOI: 10.1007/s10554-012-0036-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
Abstract
Different angiographic patterns and restenosis rate may affect diagnostic value of single-photon emission computed tomography (SPECT) in the era of drug-eluting stents (DES). We aimed to determine the ability of myocardial SPECT to detect in-stent restenosis (ISR) in patients treated with DES compared to that of patients treated with bare metal stent (BMS). We evaluated 228 consecutive patients who underwent 6 months follow-up SPECT and coronary angiography (CAG) after stent implantation. In 228 patients, 354 vessels were treated with stent implantation (BMS, n = 105; DES, n = 249) and 65 (18.4%) vessels showed ISR (angiographic % diameter stenosis ≥ 50%) at the 6-month follow-up CAG. In patients with BMS-ISR (n = 37), restenosis was primarily diffuse (70.3%), whereas patients with DES-ISR (n = 28) exhibited more focal restenosis (53.6%, p = 0.028). The sensitivity and specificity of myocardial SPECT did not differ significantly between patients with BMS and those with DES (BMS vs. DES: sensitivity 56.8 vs. 39.3%, p = 0.163; specificity 72.1 vs. 76.5%, p = 0.460). Evaluation of 71 false positive and 33 false negative lesions showed that the most common cause of false-positive results in SPECT was the perfusion decrease which improved but not disappeared compared with the baseline (46 among 71 vascular territories). Despite different patterns of restenosis and ISR rates, the diagnostic value of SPECT did not differ between BMS and DES. Further study looking at ISR in larger number of patients and using other protocol such as Fleming-Harrington Redistribution Wash-in Washout may give additional information.
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Coronary Artery Disease Progression Late After Successful Stent Implantation. J Am Coll Cardiol 2012; 59:793-9. [DOI: 10.1016/j.jacc.2011.11.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 11/10/2011] [Accepted: 11/11/2011] [Indexed: 11/18/2022]
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Georgoulias P, Valotassiou V, Tsougos I, Demakopoulos N. Myocardial Perfusion SPECT Imaging in Patients after Percutaneous Coronary Intervention. Curr Cardiol Rev 2011; 6:98-103. [PMID: 21532775 PMCID: PMC2892082 DOI: 10.2174/157340310791162677] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 01/06/2010] [Accepted: 02/25/2010] [Indexed: 11/22/2022] Open
Abstract
Coronary artery disease (CAD) is the most prevalent form of cardiovascular disease affecting about 13 million Americans, while more than one million percutaneous transluminal intervention (PCI) procedures are performed annually in the USA. The relative high occurrence of restenosis, despite stent implementation, seems to be the primary limitation of PCI. Over the last decades, single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), has proven an invaluable tool for the diagnosis of CAD and patients’ risk stratification, providing useful information regarding the decision about revascularization and is well suited to assess patients after intervention. Information gained from post-intervention MPI is crucial to differentiate patients with angina from those with exo-cardiac chest pain syndromes, to assess peri-intervention myocardial damage, to predict-detect restenosis after PCI, to detect CAD progression in non-revascularized vessels, to evaluate the effects of intervention if required for occupational reasons and to evaluate patients’ long-term prognosis. On the other hand, chest pain and exercise electrocardiography are largely unhelpful in identifying patients at risk after PCI. Although there are enough published data demonstrating the value of myocardial perfusion SPECT imaging in patients after PCI, there is still debate on whether or not these tests should be performed routinely.
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Andreini D, Pontone G, Bartorelli AL, Mushtaq S, Trabattoni D, Bertella E, Cortinovis S, Annoni A, Formenti A, Ballerini G, Agostoni P, Fiorentini C, Pepi M. High diagnostic accuracy of prospective ECG-gating 64-slice computed tomography coronary angiography for the detection of in-stent restenosis. Eur Radiol 2011; 21:1430-8. [DOI: 10.1007/s00330-011-2085-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 12/24/2010] [Accepted: 12/30/2010] [Indexed: 12/17/2022]
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25
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Hendel RC, Abbott BG, Bateman TM, Blankstein R, Calnon DA, Leppo JA, Maddahi J, Schumaecker MM, Shaw LJ, Ward RP, Wolinsky DG. The role of radionuclide myocardial perfusion imaging for asymptomatic individuals. J Nucl Cardiol 2011; 18:3-15. [PMID: 21181519 DOI: 10.1007/s12350-010-9320-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Robert C Hendel
- University of Miami Miller School of Medicine, Miami, FL, USA
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Dos Santos A, Peirano JD, Bastianello MJ, Calviño RO. Very late drug-eluting stent thrombosis post-exercise myocardial perfusion SPECT. J Nucl Cardiol 2010; 17:928-33. [PMID: 20151237 DOI: 10.1007/s12350-010-9194-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- A Dos Santos
- Department of Nuclear Medicine, Sanatorio Mater Dei, San Martín de Tours 2952, CP 1425 Ciudad Autónoma de Buenos Aires, Argentina.
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Carrabba N, Schuijf JD, de Graaf FR, Parodi G, Maffei E, Valenti R, Palumbo A, Weustink AC, Mollet NR, Accetta G, Cademartiri F, Antoniucci D, Bax JJ. Diagnostic accuracy of 64-slice computed tomography coronary angiography for the detection of in-stent restenosis: a meta-analysis. J Nucl Cardiol 2010; 17:470-8. [PMID: 20379863 PMCID: PMC2866963 DOI: 10.1007/s12350-010-9218-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Accepted: 02/28/2010] [Indexed: 01/12/2023]
Abstract
BACKGROUND We sought to evaluate the diagnostic accuracy of 64-slice multi-detector row computed tomography (MDCT) compared with invasive coronary angiography for in-stent restenosis (ISR) detection. METHODS MEDLINE, Cochrane library, and BioMed Central database searches were performed until April 2009 for original articles. Inclusion criteria were (1) 64-MDCT was used as a diagnostic test for ISR, with >50% diameter stenosis selected as the cut-off criterion for significant ISR, using invasive coronary angiography and quantitative coronary angiography as the standard of reference; (2) absolute numbers of true positive, false positive, true negative, and false negative results could be derived. Standard meta-analytic methods were applied. RESULTS Nine studies with a total of 598 patients with 978 stents included were considered eligible. On average, 9% of stents were unassessable (range 0-42%). Accuracy tests with 95% confidence intervals (CIs) comparing 64-MDCT vs invasive coronary angiography showed that pooled sensitivity, specificity, positive and negative likelihood ratio (random effect model) values were: 86% (95% CI 80-91%), 93% (95% CI 91-95%), 12.32 (95% CI 7.26-20.92), 0.18 (95% CI 0.12-0.28) for binary ISR detection. The symmetric area under the curve value was 0.94, indicating good agreement between 64-MDCT and invasive coronary angiography. CONCLUSIONS 64-MDCT has a good diagnostic accuracy for ISR detection with a particularly high negative predictive value. However, still a relatively large proportion of stents remains uninterpretable. Accordingly, only in selected patients, 64-MDCT may serve as a potential alternative noninvasive method to rule out ISR.
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Affiliation(s)
- Nazario Carrabba
- Division of Cardiology, Careggi Hospital, V.le Morgagni, 85 Florence, Italy.
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Prognosis of asymptomatic coronary artery disease after percutaneous coronary intervention. Am J Cardiol 2010; 105:1507-12. [PMID: 20494653 DOI: 10.1016/j.amjcard.2010.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 01/11/2010] [Accepted: 01/11/2010] [Indexed: 11/24/2022]
Abstract
The appropriate treatment for asymptomatic patients with obstructive coronary stenoses is controversial. The effect of percutaneous coronary intervention (PCI) on the prognosis of such patients is unknown. The present study compared the 1-year outcomes of patients with stable coronary artery disease (CAD) with regard to the presence or absence of symptoms after elective PCI. A total of 1,944 consecutive patients with stable CAD who had undergone elective PCI were studied. They were divided into 2 groups according to symptom status: asymptomatic (n = 1,052) and symptomatic (n = 892). A 1-year follow-up evaluation was conducted by office visit and telephone interview. The end points consisted of all-cause mortality, nonfatal myocardial infarction, and target vessel revascularization. Patients without angina pectoris were older, predominantly men, and more frequently had chronic renal insufficiency, a previous myocardial infarction, a coronary artery bypass graft, and a lower left ventricular ejection fraction. The 1-year mortality rate was greater in the asymptomatic patients (43 [4.1%] vs 16 [1.8%], p = 0.003). The incidence of nonfatal myocardial infarction and target vessel revascularization was similar in the 2 groups (15 [1.5%] vs 12 [1.4%], p = 0.85; and 69 [6.7%] vs 68 [7.7%], p = 0.39, respectively). On multivariate analysis, the absence of symptoms was a strong independent predictor of 1-year mortality (p = 0.017). In conclusion, in patients with stable CAD undergoing elective PCI, the absence of symptoms was associated with an increase in 1-year mortality.
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Evaluation of coronary artery in-stent restenosis by 64-section computed tomography: factors affecting assessment and accurate diagnosis. J Thorac Imaging 2010; 25:57-63. [PMID: 20160604 DOI: 10.1097/rti.0b013e3181b5d813] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To determine factors affecting the ability of 64-multislice computed tomography (MSCT) to detect, assess, and accurately diagnose significant coronary arterial in-stent restenosis (ISR). MATERIALS AND METHODS The institutional review board approved this study and waived informed consent. Sixty patients underwent CT coronary angiography using 64-MSCT, after implantation of coronary artery stents (n=91). We assessed diagnostic accuracy for ISR with CT in comparison with conventional coronary angiography as the gold standard, visually and with measurement of in-stent coronary lumen density. Possible factors that influenced the diagnostic performance of CT were evaluated, which included image quality (IQ), stent characteristics, and location. RESULTS Sixty-nine stents (75.8%) were assessable. Low IQ, location in the left circumflex coronary artery, and narrow stent diameter were associated with poor assessment (P<0.05). In stents that could be assessed, sensitivity, specificity, positive predictive value, and negative predictive value of 64-MSCT were 90.0%, 73.5%, 58.1%, and 94.7%, respectively, for significant ISR. The diagnostic accuracy in assessable stents showed a significant increase with better IQ, thinner strut thickness, and nondrug eluting stent. False-positive diagnoses of ISR by CT were explained by coronary lumen density measurements. CONCLUSIONS Evaluation of stents by 64-MSCT is not recommended in stents with diameters of < or = 2.75 mm or stents located at the left circumflex coronary artery. The diagnostic accuracy of 64-MSCT is affected by IQ and strut thickness in assessable stents. Significant ISR can be excluded with high reliability in selected patients.
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Andreini D, Pontone G, Mushtaq S, Pepi M, Bartorelli AL. Multidetector Computed Tomography Coronary Angiography for the Assessment of Coronary In-Stent Restenosis. Am J Cardiol 2010; 105:645-55. [DOI: 10.1016/j.amjcard.2009.10.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 10/14/2009] [Accepted: 10/14/2009] [Indexed: 10/19/2022]
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Predictors of impaired heart rate recovery: a myocardial perfusion SPECT study. ACTA ACUST UNITED AC 2009; 17:303-8. [DOI: 10.1097/hjr.0b013e32833188e0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The use of functional tests and planned coronary angiography after percutaneous coronary revascularization in clinical practice.Results from the AFTER multicenter study. Int J Cardiol 2009; 137:151-7. [DOI: 10.1016/j.ijcard.2008.06.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 06/17/2008] [Accepted: 06/28/2008] [Indexed: 11/19/2022]
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Hsu CC, Chen YW, Hao CL, Chong JT, Lee CI, Tan HT, Wu MS, Wu JC. Comparison of automated 4D-MSPECT and visual analysis for evaluating myocardial perfusion in coronary artery disease. Kaohsiung J Med Sci 2009; 24:445-52. [PMID: 19073376 DOI: 10.1016/s1607-551x(09)70001-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to assess the reproducibility and diagnostic performance for coronary artery disease (CAD) of an automated software package, 4D-MSPECT, and compare the results with a visual approach. We enrolled 60 patients without previously known CAD, who underwent dual-isotope rest Tl-201/stress Tc-99m sestamibi myocardial perfusion imaging and subsequent coronary angiography within 3 months. The automated summed stress score (A-SSS), summed rest score (A-SRS) and summed difference score (A-SDS) were obtained using a 17-segment five-point scale model with 4D-MSPECT. For intraobserver and interobserver variability assessment, automated scoring was done by a nuclear medicine physician twice and by a nuclear medicine technologist. The visual summed stress score (V-SSS), summed rest score (V-SRS), and summed difference score (V-SDS) were obtained by consensus of two nuclear medicine physicians. The intraobserver and interobserver agreements of automated segmental scores were excellent. The intraobserver and interobserver summed scores also correlated well. Agreements between visual and automated segmental scores were moderate (weighted kappa of 0.55 and 0.50 for stress and rest images, respectively). Correlations between automated and visual summed scores were high, with correlation coefficients of 0.89, 0.85 and 0.82 for SSS, SRS and SDS, respectively (all p < 0.001). The receiver operating characteristic area under the curve for diagnosis of CAD by V-SSS, V-SDS, A-SSS and A-SDS were 0.78 +/- 0.06, 0.87 +/- 0.05, 0.84 +/- 0.05 and 0.90 +/- 0.04, respectively. A-SDS had better diagnostic performance than A-SSS and V-SSS (p = 0.043 and p = 0.032, respectively), whereas there was no statistically significant difference between A-SDS and V-SDS (p = 0.56). Using V-SDS > or = 2 as a diagnostic threshold, the sensitivity, specificity, and accuracy for CAD were 83.7%, 76.5% and 81.7%, respectively. Using A-SDS > or = 3 as a diagnostic threshold, the sensitivity, specificity, and accuracy for CAD were 79.1%, 82.4% and 80.0%, respectively. In conclusion, the reproducibility of automated semiquantitative analysis with 4D-MSPECT was excellent. The diagnostic performance of automated semiquantitative analysis with 4D-MSPECT was comparable with the visual approach.
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Affiliation(s)
- Chien-Chin Hsu
- Department of Nuclear Medicine, Pingtung Christian Hospital, Pingtung, Taiwan
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Citro R, Voci P, Pizzuto F, Maione AG, Patella MM, Bossone E, Provenza G, Gregorio G, Mariano E, Feinstein M, Athanassopoulos G, Puddu PE. Clinical value of echocardiographic assessment of coronary flow reserve after left anterior descending coronary artery stenting in an unselected population. J Cardiovasc Med (Hagerstown) 2009; 9:1254-9. [PMID: 19001933 DOI: 10.2459/jcm.0b013e328312954e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Transthoracic Doppler echocardiography is a valuable tool to measure coronary flow reserve (CFR) and detect in-stent restenosis (ISR) after percutaneous coronary angioplasty in selected series of patients. OBJECTIVES To assess the usefulness of coronary flow reserve measured by echocardiography in detecting significant (> or =70%) ISR of the left anterior descending coronary artery in a large unselected population. METHODS Two hundred and twenty-three patients (age 61 +/- 10 years; 168 men) treated with left anterior descending stenting underwent CFR measurement by transthoracic Doppler echocardiography and venous adenosine infusion 24-72 h before control coronary angiography. Coronary-active drugs were continued, and patients with multiple risk factors and old anterior-apical myocardial infarction were included. RESULTS Significant ISR occurred in 56 patients (25%). Patients with ISR had higher basal coronary flow velocity (27 +/- 10 cm/s vs. 24 +/- 7 cm/s; P < 0.002) and lower CFR (1.5 +/- 0.5 vs. 2.7 +/- 0.6; P < 0.0001) than those without ISR. A linear relation was found between ISR and CFR (r = -0.73; P < 0.0001) and remained significant after adjustment for blood pressure and heart rate (r = -0.74; P < 0.0001). A CFR less than two identified significant ISR (sensitivity 88%, specificity 88%, area under the curve = 0.943; P < 0.001). In a multivariate model of CFR prediction, myocardial infarction and heart rate were slightly contributory (ss = -0.19, P < 0.01; ss = -0.16, P < 0.03, respectively), whereas ISR had a large influence (ss = -0.66; P < 0.0001). The inverse correlation between ISR and CFR persisted in patients with myocardial infarction (r = -0.64; P < 0.0001) and in those treated with beta-blockers (r = -0. 71; P < 0.0001). CONCLUSION Echocardiographic measurement of CFR detects significant left anterior descending ISR in unselected patients with multiple risk factors, old anterior-apical myocardial infarction, and taking beta-blockers.
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Affiliation(s)
- Rodolfo Citro
- San Luca Hospital, Vallo della Lucania, Salerno, Italy.
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Incremental prognostic value of 99mTc-tetrofosmin myocardial SPECT after percutaneous coronary intervention. Ann Nucl Med 2009; 22:899-909. [DOI: 10.1007/s12149-008-0191-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 07/09/2008] [Indexed: 11/26/2022]
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Use of copeptin in the detection of myocardial ischemia. Clin Chim Acta 2009; 399:69-73. [DOI: 10.1016/j.cca.2008.09.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 08/25/2008] [Accepted: 09/14/2008] [Indexed: 11/17/2022]
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Long-Term Prognostic Value of Tc-99m Tetrofosmin Myocardial Gated-SPECT Imaging in Asymptomatic Patients After Percutaneous Coronary Intervention. Clin Nucl Med 2008; 33:743-7. [DOI: 10.1097/rlu.0b013e318187ee88] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To examine the association of nonpain symptoms in men and women with exercise-related silent ischemia, as well as the independence of these findings from other clinical factors. METHODS A prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging. Analyses were performed on 60 women and 155 men with no angina but medical perfusion imaging evidence of ischemia during exercise. MEASURES The presence of various non-pain-related symptoms. Ischemia is indicated by myocardial perfusion defects on exercise stress testing with single photon emission computed tomography. RESULTS Women reported more nonangina symptoms than men (P<0.05). They experienced fatigue, hot flushes, tense muscles, shortness of breath and headaches more frequently (P<0.05). Symptoms relating to muscle tension and diaphoresis were associated with ischemia after controlling for pertinent clinical covariates. However, the direction of association differed according to sex and history of coronary artery disease events or procedures. Sensitivity of the detection models showed modest improvements with the addition of these symptoms. CONCLUSIONS While patients who experience silent ischemia experience a number of nonpain symptoms, those symptoms may not be sufficiently specific to ischemia, nor sensitive in detecting ischemia, to be of particular help to physicians in the absence of other clinical information.
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Zellweger MJ, Kaiser C, Brunner-La Rocca HP, Buser PT, Osswald S, Weiss P, Mueller-Brand J, Pfisterer ME. Value and limitations of target-vessel ischemia in predicting late clinical events after drug-eluting stent implantation. J Nucl Med 2008; 49:550-6. [PMID: 18344439 DOI: 10.2967/jnumed.107.046771] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Drug-eluting stents reduce clinical events related to restenosis but may be complicated by late stent-thrombosis. Whereas assessment of target-vessel ischemia by myocardial perfusion scintigraphy identifies relevant restenosis noninvasively, it is unknown whether this technique may also predict late clinical events related to late stent-thrombosis and to restenosis after drug-eluting stent implantation. METHODS All 826 patients treated with stenting between May 2003 and May 2004 were included in the Basel Stent Cost Effectiveness Trial (Basel Stent Kosten-Effektivitäts Trial, or BASKET) and randomized (2:1) to drug-eluting stents or bare metal stents. Myocardial scintigraphy was performed on 476 (64%) of 747 patients without major events after 6 mo. Patients were followed for 1 y for cardiac death, nonfatal myocardial infarction, and target-vessel revascularization due to restenosis or late stent-thrombosis. RESULTS The rate of target-vessel ischemia in these patients was lower with drug-eluting stents than with bare metal stents (5.4% vs. 10.4%, P = 0.045), similar to the rates of symptom-driven target-vessel revascularization up to 6 mo (4.6% vs. 7.8%, P = 0.08). Ischemia was silent in 68%. During follow-up, patients with target-vessel ischemia had higher event rates than did patients without ischemia (32.4% vs. 6.1%, P < 0.001); however, ischemia did not predict late stent-thrombosis (0/11 cases). CONCLUSION The rate of clinical restenosis assessed scintigraphically was lower with drug-eluting stents than with bare metal stents and paralleled that of symptom-driven target-vessel revascularization. Target-vessel ischemia independently predicted late clinical events related to restenosis but not to late stent-thrombosis.
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The value of stress single-photon emission computed tomography imaging performed routinely at 6 months in asymptomatic patients for predicting angiographic restenosis after successful direct percutaneous intervention for acute ST elevation myocardial infarction. Coron Artery Dis 2008; 19:89-97. [DOI: 10.1097/mca.0b013e3282f0a288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patel RN, Arteaga RB, Mandawat MK, Thornton JW, Robinson VJB. Pharmacologic Stress Myocardial Perfusion Imaging. South Med J 2007; 100:1006-14; quiz 1004. [PMID: 17943047 DOI: 10.1097/smj.0b013e318153f9c6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Xanthos T, Ekmektzoglou KA, Papadimitriou L. Reviewing myocardial silent ischemia: specific patient subgroups. Int J Cardiol 2007; 124:139-48. [PMID: 17566575 DOI: 10.1016/j.ijcard.2007.04.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 11/30/2006] [Accepted: 04/01/2007] [Indexed: 11/28/2022]
Abstract
Silent myocardial ischemia (SMI) is a relatively common, yet poorly understood, clinical entity. The most accurate means of detecting SMI and the precise treatment endpoints remain unclear. However, the presence of SMI correlates with the likelihood of future adverse cardiac events. Evidence suggests that patients at high risk of severe cardiac ischemia, even with the absence of symptoms, derive the greatest benefit from an aggressive diagnostic and therapeutic approach. This paper is giving a detailed review of SMI in regards to specific patient subgroups, i.e. populations with diabetes mellitus, hypertension, elderly patients, post-revascularization patients, women, the suggested screening procedures for each subgroup, as well as the emersion of new markers for the selection of high-risk patients for screening.
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Affiliation(s)
- Theodoros Xanthos
- Department of Experimental Surgery and Surgical Research N.S.Christeas, Athens School of Medicine, Athens, Greece
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Silent Ischemia. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Solodky A, Assali AR, Mats I, Ben-Gal T, Kornowski R, Battler A, Zafrir N. Prognostic Value of Myocardial Perfusion Imaging in Symptomatic and Asymptomatic Patients after Percutaneous Coronary Intervention. Cardiology 2006; 107:38-43. [PMID: 16741356 DOI: 10.1159/000093611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Accepted: 04/04/2006] [Indexed: 11/19/2022]
Abstract
The aim of this study was to evaluate the value of myocardial perfusion imaging (MPI) in predicting major adverse cardiovascular events (MACE) in symptomatic and asymptomatic patients after percutaneous coronary intervention (PCI). We revised retrospectively patients after PCI that underwent MPI and were followed for a year for the presence of MACE. We found no differences in the incidence of MACE between symptomatic and asymptomatic patients. On multivariate analysis, the presence of ischemia by MPI was the most important independent predictor of MACE (OR 5.09, CI 95% 2.15-12.05, p < 0.001). The presence of myocardial ischemia by MPI performed after PCI, and no symptom status, predicts a worse outcome during 1 year of follow-up.
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Affiliation(s)
- Alejandro Solodky
- Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Elhendy A, Schinkel AFL, van Domberg RT, Bax JJ, Valkema R, Poldermans D. Non-invasive diagnosis of in stent stenosis by stress 99m technetium tetrofosmin myocardial perfusion imaging. Int J Cardiovasc Imaging 2006; 22:657-62. [PMID: 16628382 DOI: 10.1007/s10554-006-9087-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Accepted: 03/01/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to assess the accuracy of stress 99m technetium tetrofosmin myocardial perfusion imaging for the diagnosis of in stent stenosis (ISS). METHODS We studied 72 patients who underwent exercise or dobutamine stress 99m technetium tetrofosmin imaging, 0.9+/-0.5 years after percutaneous coronary interventions in which stents were deployed. Coronary angiography was performed within 3 months of the stress test. ISS was defined as > or =50% stenosis in a coronary segment with previous stenting. Significant coronary artery disease (CAD) was defined as > or =50% stenosis within or outside the stented coronary segment. RESULTS The stent was deployed in 1 coronary artery in 52 patients, and in 2 coronary arteries in 20 patients (a total of 92 detected in 42 (58%) patients (51 stents). Reversible perfusion abnormalities were present in 34 of patients with ISS (sensitivity=81%, CI 70-94). Regional sensitivity for diagnosis of stenosis per stent was 76% (CI 65-88), specificity was 83% (CI 71-94) and accuracy was 79% (CI 69-85). Reversible perfusion abnormalities were detected in > or =2 vascular distributions in 15 of 22 patients with multi-vessel CAD and in 5 of 50 patients without (sensitivity for identifying multivessel CAD=68%, CI 50-89; specificity=90%, CI 82-98; and accuracy=83%, CI 75-90). CONCLUSION Stress 99m technetium tetrofosmin myocardial perfusion imaging is a useful non-invasive technique for the diagnosis of in stent stenosis and extent of CAD in patients with previous percutaneous coronary artery interventions.
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Affiliation(s)
- Abdou Elhendy
- Thoraxcenter, University Hospital Rotterdam, Rotterdam, The Netherlands.
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Galassi AR, Grasso C, Azzarelli S, Ussia G, Moshiri S, Tamburino C. Usefulness of exercise myocardial scintigraphy in multivessel coronary disease after incomplete revascularization with coronary stenting. Am J Cardiol 2006; 97:207-15. [PMID: 16442365 DOI: 10.1016/j.amjcard.2005.08.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 08/05/2005] [Accepted: 08/05/2005] [Indexed: 10/25/2022]
Abstract
The aim of this prospective study was to evaluate the prognostic value of exercise myocardial scintigraphy in patients who undergo incomplete revascularization with percutaneous coronary stenting. In 322 consecutive patients (mean age 61 +/- 10 years), exercise technetium-99m-tetrofosmin single-photon emission computed tomography scintigraphy was prospectively performed 4 to 6 months after an incomplete revascularization procedure. Follow-up lasted < or = 84 months (median 33). Patients with normal findings were at low risk of cardiac events compared with patients with mildly abnormal and severely abnormal findings (yearly event rate 1.5% vs 5.1% and 8.5%, respectively, p < 0.01). A significant difference was observed in hard, soft, and composite event-free survival among patients with normal, mildly abnormal, and severely abnormal findings (p < 0.01, p < 0.03, and p < 0.01, respectively). Nuclear data provided significant incremental prognostic value for cardiac events compared with the clinical, angiographic, and exercise test findings. In conclusion, in patients with incomplete revascularization procedures, exercise myocardial scintigraphy provides significant independent information concerning the subsequent risk of cardiac events, with an annualized event rate of < 2% for patients with normal scan findings. Myocardial scintigraphy is able to provide incremental prognostic information after adjusting for clinical, angiographic, and exercise variables.
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Affiliation(s)
- Alfredo R Galassi
- Clinical Division of Cardiology, Department of Internal Medicine and Systemic Disease, Ferrarotto Hospital, University of Catania, Catania, Italy.
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Abstract
The utility of stress myocardial perfusion imaging (MPI) for the diagnosis and prognosis of coronary artery disease (CAD) has been firmly established in numerous clinical studies and has become an essential component of clinical practice. Stress MPI is now used regularly to guide initial risk stratification and management of patients with CAD. Because stress MPI provides an assessment of the physiologic significance of CAD, it is a particularly attractive procedure for assessing follow-up risk. Today, sequential stress MPI is being used increasingly to track disease progression, assess follow-up risk, detect restenosis following revascularization, and evaluate the efficacy of aggressive medical therapy and risk-factor modification. By providing serial snapshots of the disease and its impact on perfusion, sequential stress MPI may alter treatment decisions and ultimately improve long-term patient management and outcomes. Use of sequential stress MPI to detect changes in perfusion following surgical or medical therapies is being tested currently in the Clinical Outcomes Using Revascularization and Aggressive Drug Evaluation (COURAGE) and Adenosine Sestamibi Single-Photon Emission Computed Tomography Postinfarction Evaluation (INSPIRE) trials.
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Affiliation(s)
- Leslee J Shaw
- Department of Medicine and Imaging, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Rizzo M, Barbagallo CM, Noto D, Pace A, Cefalú AB, Pernice V, Pinto V, Rubino A, Pieri D, Traina M, Frasheri A, Notarbartolo A, Averna MR. Family history, diabetes and extension of coronary atherosclerosis are strong predictors of adverse events after PTCA: A one-year follow-up study. Nutr Metab Cardiovasc Dis 2005; 15:361-367. [PMID: 16216722 DOI: 10.1016/j.numecd.2005.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Revised: 02/22/2005] [Accepted: 02/24/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM In this study we addressed some open questions in patients with coronary artery disease (CAD). First, we analysed which of the traditional risk factors was associated with the spreading of coronary stenosis and second, we aimed to identify if any variable was predictive of post-percutaneous transluminal coronary angioplasty (PTCA) clinical events. METHODS AND RESULTS We collected a consecutive series of patients with CAD (n=301) and in the subgroup of patients undergoing PTCA (n=135) we performed a prospective one-year follow-up study recording cardiovascular morbidity and total mortality. According to the extension of coronary atherosclerosis, we found a significant relationship with the prevalence of diabetes in men and with plasma HDL-cholesterol concentrations in women. The follow-up was completed in 95% of patients; we did not document any death whereas clinical events were registered in 16% of patients. At univariate analysis, we found that patients with clinical events had a higher prevalence of family history of CAD (43% vs 14%, p<0.005), diabetes (52% vs 21%, p<0.005) and multivessel disease (52% vs 35%, p<0.05). Multivariate analysis (logistic regression) confirmed that family history of CAD (OR 4.6, 95% CI 1.7-12.8, p<0.005), diabetes (OR 4.0, 95% CI 1.5-10.6, p<0.01) and multivessel disease (OR 2.8, 95% CI 1.1-7.4, p<0.05) were the only variables predictive of clinical events. CONCLUSIONS In this study, factors associated with the spreading of coronary stenosis were different according to the gender. Moreover, the presence of diabetes and multivessel disease had a negative impact on the long-term prognosis of patients undergoing PTCA. In addition, the family history of CAD represented in our study a strong predictor of clinical events. We suggest that in the management of post-PTCA patients, the role of individual baseline clinical characteristics must be taken into account and that subjects with a family history of premature CAD, diabetes and a wide extension of coronary disease represent those with the highest risk.
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Affiliation(s)
- Manfredi Rizzo
- Department of Clinical Medicine and Emerging Diseases, University of Palermo, Via del Vespro 141, 90127 Palermo, Italy
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Gabriel Steg P, Himbert D. Unmet medical needs and therapeutic opportunities in stable angina. Eur Heart J Suppl 2005. [DOI: 10.1093/eurheartj/sui049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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