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Møller PL, Rohde PD, Dahl JN, Rasmussen LD, Nissen L, Schmidt SE, McGilligan V, Gudbjartsson DF, Stefansson K, Holm H, Bentzon JF, Bøttcher M, Winther S, Nyegaard M. Predicting the presence of coronary plaques featuring high-risk characteristics using polygenic risk scores and targeted proteomics in patients with suspected coronary artery disease. Genome Med 2024; 16:40. [PMID: 38509622 PMCID: PMC10953133 DOI: 10.1186/s13073-024-01313-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 03/12/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND The presence of coronary plaques with high-risk characteristics is strongly associated with adverse cardiac events beyond the identification of coronary stenosis. Testing by coronary computed tomography angiography (CCTA) enables the identification of high-risk plaques (HRP). Referral for CCTA is presently based on pre-test probability estimates including clinical risk factors (CRFs); however, proteomics and/or genetic information could potentially improve patient selection for CCTA and, hence, identification of HRP. We aimed to (1) identify proteomic and genetic features associated with HRP presence and (2) investigate the effect of combining CRFs, proteomics, and genetics to predict HRP presence. METHODS Consecutive chest pain patients (n = 1462) undergoing CCTA to diagnose obstructive coronary artery disease (CAD) were included. Coronary plaques were assessed using a semi-automatic plaque analysis tool. Measurements of 368 circulating proteins were obtained with targeted Olink panels, and DNA genotyping was performed in all patients. Imputed genetic variants were used to compute a multi-trait multi-ancestry genome-wide polygenic score (GPSMult). HRP presence was defined as plaques with two or more high-risk characteristics (low attenuation, spotty calcification, positive remodeling, and napkin ring sign). Prediction of HRP presence was performed using the glmnet algorithm with repeated fivefold cross-validation, using CRFs, proteomics, and GPSMult as input features. RESULTS HRPs were detected in 165 (11%) patients, and 15 input features were associated with HRP presence. Prediction of HRP presence based on CRFs yielded a mean area under the receiver operating curve (AUC) ± standard error of 73.2 ± 0.1, versus 69.0 ± 0.1 for proteomics and 60.1 ± 0.1 for GPSMult. Combining CRFs with GPSMult increased prediction accuracy (AUC 74.8 ± 0.1 (P = 0.004)), while the inclusion of proteomics provided no significant improvement to either the CRF (AUC 73.2 ± 0.1, P = 1.00) or the CRF + GPSMult (AUC 74.6 ± 0.1, P = 1.00) models, respectively. CONCLUSIONS In patients with suspected CAD, incorporating genetic data with either clinical or proteomic data improves the prediction of high-risk plaque presence. TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT02264717 (September 2014).
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Affiliation(s)
- Peter Loof Møller
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Palle Duun Rohde
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Jonathan Nørtoft Dahl
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Laust Dupont Rasmussen
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Louise Nissen
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Samuel Emil Schmidt
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Victoria McGilligan
- Personalized Medicine Centre, School of Medicine, Ulster University, Derry, Northern Ireland
| | - Daniel F Gudbjartsson
- deCODE Genetics/Amgen, Inc, Reykjavik, Iceland
- School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
| | - Kari Stefansson
- deCODE Genetics/Amgen, Inc, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Hilma Holm
- deCODE Genetics/Amgen, Inc, Reykjavik, Iceland
| | - Jacob Fog Bentzon
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
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Aksu F, Ahmed SA. Gensini Score's Severity and Its Relationship with Risk Factors for Coronary Artery Disease Among Patients Who Underwent Angiography in Somalia's Largest PCI Centre. Int J Gen Med 2024; 17:187-192. [PMID: 38268859 PMCID: PMC10807280 DOI: 10.2147/ijgm.s384626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/18/2024] [Indexed: 01/26/2024] Open
Abstract
Aim Coronary artery diseases (CAD) are chronic disorders in which atherosclerosis plays a major role in their pathogenesis. Their severity is directly related to cardiovascular outcomes. The assessment of Coronary Artery severity is quite complex, in which different parameters are used, such as the gensini score, syntax score, etc. Methods This was a retrospective study of adult (≥18 years) patients who underwent angiography in Mogadishu Somali Türkiye Training and Research Hospital from June 2022 to September 2023. Gensini scores were calculated to determine the extent and severity of atherosclerosis among patients with coronary artery disease. Results A total of 278 participants (78% male and 22%% women) were analyzed. Their risk factors were assessed with hypertension being the leading risk factor (48%). While a significant relationship was found between gensini score and dyslipidemia in patients with chronic ischemic heart disease (p 0.035), no significance was found with other risk factors On the other hand, the Gensini score had a significant correlation with the final decision of management (medical, PCI vs CABG). Conclusion This study indicated that the Gensini score can be used as a guide for CAD decisions.
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Affiliation(s)
- Feyza Aksu
- Department of Cardiology, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia
| | - Said Abdirahman Ahmed
- Department of Cardiology, Mogadishu Somalia Turkish Training and Research Hospital, Mogadishu, Somalia
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Brix GS, Rasmussen LD, Rohde PD, Schmidt SE, Nyegaard M, Douglas PS, Newby DE, Williams MC, Foldyna B, Knuuti J, Bøttcher M, Winther S. Calcium Scoring Improves Clinical Management in Patients With Low Clinical Likelihood of Coronary Artery Disease. JACC Cardiovasc Imaging 2024:S1936-878X(23)00527-2. [PMID: 38180413 DOI: 10.1016/j.jcmg.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Coronary artery calcium scoring (CACS) improves management of chest pain patients. However, it is unknown whether the benefit of CACS is dependent on the clinical likelihood (CL). OBJECTIVES This study aims to investigate for which patients CACS has the greatest benefit when added to a CL model. METHODS Based on data from a clinical database, the CL of obstructive coronary artery disease (CAD) was calculated for 39,837 patients referred for cardiac imaging due to symptoms suggestive of obstructive CAD. Patients were categorized according to the risk factor-weighted (RF-CL) model (very low, ≤5%; low, >5 to ≤15%; moderate >15 to ≤50%; high, >50%). CL was then recalculated incorporating the CACS result (CACS-CL). Reclassification rates and the number needed to test with CACS to reclassify patients were calculated and validated in 3 independent cohorts (n = 9,635). RESULTS In total, 15,358 (39%) patients were down- or upclassified after including CACS. Reclassification rates were 8%, 75%, 53%, and 30% in the very low, low, moderate, and high RF-CL categories, respectively. Reclassification to very low CACS-CL occurred in 48% of reclassified patients. The number needed to test to reclassify 1 patient from low RF-CL to very low CACS-CL was 2.1 with consistency across age, sex, and cohorts. CACS-CL correlated better to obstructive CAD prevalence than RF-CL. CONCLUSIONS Added to an RF-CL model for obstructive CAD, CACS identifies more patients unlikely to benefit from further testing. The number needed to test with CACS to reclassify patients depends on the pretest RF-CL and is lowest in patients with low (>5% to ≤15%) likelihood of CAD.
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Affiliation(s)
- Gitte S Brix
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Laust D Rasmussen
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Palle D Rohde
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Samuel E Schmidt
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Borek Foldyna
- Department of Radiology, Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu, Turku, Finland
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Rasmussen LD, Albertsen LEB, Nissen L, Ejlersen JA, Isaksen C, Murphy T, Søndergaard HM, Kirk J, Brix L, Gormsen LC, Petersen SE, Bøttcher M, Winther S. Diagnostic performance of clinical likelihood models of obstructive coronary artery disease to predict myocardial perfusion defects. Eur Heart J Cardiovasc Imaging 2023; 25:39-47. [PMID: 37282714 DOI: 10.1093/ehjci/jead135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/18/2023] [Accepted: 06/02/2023] [Indexed: 06/08/2023] Open
Abstract
AIMS Clinical likelihood (CL) models are designed based on a reference of coronary stenosis in patients with suspected obstructive coronary artery disease. However, a reference standard for myocardial perfusion defects (MPDs) could be more appropriate. We aimed to investigate the ability of the 2019 European Society of Cardiology pre-test probability (ESC-PTP), the risk-factor-weighted (RF-CL) model, and coronary artery calcium score-weighted (CACS-CL) model to diagnose MPDs. METHODS AND RESULTS Symptomatic stable de novo chest pain patients (n = 3374) underwent coronary computed tomography angiography and subsequent myocardial perfusion imaging by single-photon emission computed tomography, positron emission tomography, or cardiac magnetic resonance. For all modalities, MPD was defined as coronary computed tomography angiography with suspected stenosis and stress-perfusion abnormality in ≥2 segments. The ESC-PTP was calculated based on age, sex, and symptom typicality, and the RF-CL and CACS-CL additionally included a number of risk factors and CACS. In total, 219/3374 (6.5%) patients had an MPD. Both the RF-CL and the CACS-CL classified substantially more patients to low CL (<5%) of obstructive coronary artery disease compared with the ESC-PTP (32.5 and 54.1 vs. 12.0%, P < 0.001) with preserved low prevalences of MPD (<2% for all models). Compared with the ESC-PTP [area under the receiver-operating characteristic curve (AUC) 0.74 (0.71-0.78)], the discrimination of having an MPD was higher for the CACS-CL model [AUC 0.88 (0.86-0.91), P < 0.001], while it was similar for the RF-CL model [AUC 0.73 (0.70-0.76), P = 0.32]. CONCLUSION Compared with basic CL models, the RF-CL and CACS-CL models improve down classification of patients to a very low-risk group with a low prevalence of MPD.
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Affiliation(s)
- Laust Dupont Rasmussen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
| | | | - Louise Nissen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
| | | | - Christin Isaksen
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Theodore Murphy
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | | | - Jane Kirk
- Department of Cardiology, Regional Hospital Central Jutland, Silkeborg, Denmark
| | - Lau Brix
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Comparative Medicine Lab, Aarhus University, Aarhus, Denmark
| | - Lars Christian Gormsen
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, UK
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
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Sliwicka O, Baggiano A, Sechopoulos I, Pontone G. Stress-only dynamic computed tomography perfusion protocol (CTP) alone without computed tomography coronary angiography (CCTA) has limited specificity to diagnose ischemia: A retrospective two-center study. Eur J Radiol 2023; 169:111152. [PMID: 37866193 DOI: 10.1016/j.ejrad.2023.111152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/20/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE To investigate diagnostic performance of stress-only dynamic myocardial computed tomography perfusion (CTP) without computed tomography coronary angiography (CCTA) to diagnose ischemia with invasive fractional flow reserve (FFR) as a reference standard. METHOD 135 datasets (68 positive for ischemia with invasive FFR < 0.8) acquired with a 256-slice CT system (Revolution, GE Healthcare, Chicago, IL, USA) were retrieved, postprocessed with a deep learning-based algorithm (Advanced intelligent Clear-IQ Engine (AiCE), Canon Medical Systems, Otawara, Japan) (FC03/cardiac kernel, 8 mm slice thickness), analyzed using a dedicated workstation (Vitrea research 7.11.0. Vital Images, Minnetonka, MN, USA), and loaded into a clinical workstation (CardIQ, GE Healthcare, Chicago, IL, USA) for review. Ten observers with various experience from two research sites evaluated the post-processed images, perfusion slices and maps to indicate presence vs absence of perfusion defect and its probability (five-point Likert scale). Binary decisions and probability scores were used to calculate sensitivity and specificity for each reader, and to create receiver operating characteristics (ROC) curves, respectively. Furthermore, the correlation coefficient (ICC) was computed. ROC AUC of a purely quantitative analysis was obtained thanks to a color-coded map with a fixed scale superimposed on myocardial walls displaying myocardial blood flow (MBF) values. RESULTS The overall case-based sensitivity and specificity for the detection of perfusion deficit were 0.79 and 0.30, respectively. No significant differences were detected in the AUC across readers (p value = 0.66). The AUC values were 0.50, 0.58, 0.63, 0.59, 0.45, 0.60, 0.56, 0.61, 0.52, 0.61. Absolute reader agreement ICC was 0.60 (good agreement) for an average case. CONCLUSION Dynamic CTP alone has good sensitivity, but low specificity when analyzed without CCTA. These findings reinforce the need to guide the interpretation functional test with the knowledge of coronary artery anatomy.
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Affiliation(s)
- Olga Sliwicka
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andrea Baggiano
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ioannis Sechopoulos
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands; Technical Medicine Center, University of Twente, Enschede, the Netherlands.
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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Pontone G, Rossi A, Gimelli A, Neglia D. Should we choose CT angiography first instead of SPECT/PET first for the diagnosis and management of coronary artery disease? Atherosclerosis 2023; 385:117315. [PMID: 37890440 DOI: 10.1016/j.atherosclerosis.2023.117315] [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: 06/21/2023] [Revised: 09/04/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
In patients presenting with chest pain, current guidelines recommend the use of coronary computed tomography angiography and single-photon emission tomography/positron emission tomography, both with equal class 1 indication and level of evidence A. There is no clear recommendation on which test should be used as a first-line test. The choice of the test should be based on individualized clinical risk assessment, patient characteristics, local expertise/availability, and patient preferences. In this context, it is fair to ask which non-invasive imaging test to choose. The debate reproduced in this article answers this question by summarizing the considerations in selecting present state-of-the-art criteria of the right test for the right patient to ensure efficient resource utilization, minimize unnecessary testing, and maximize diagnostic accuracy and therapeutic efficacy.
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Affiliation(s)
- Gianluca Pontone
- Department of Periooperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland
| | - Alessia Gimelli
- Imaging Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Danilo Neglia
- Cardiovascular and Imaging Departments, Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Sant'Anna School of Advanced Studies, Pisa, Italy
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Raisi-Estabragh Z, Martin-Isla C, Nissen L, Szabo L, Campello VM, Escalera S, Winther S, Bøttcher M, Lekadir K, Petersen SE. Radiomics analysis enhances the diagnostic performance of CMR stress perfusion: a proof-of-concept study using the Dan-NICAD dataset. Front Cardiovasc Med 2023; 10:1141026. [PMID: 37781298 PMCID: PMC10541220 DOI: 10.3389/fcvm.2023.1141026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Objectives To assess the feasibility of extracting radiomics signal intensity based features from the myocardium using cardiovascular magnetic resonance (CMR) imaging stress perfusion sequences. Furthermore, to compare the diagnostic performance of radiomics models against standard-of-care qualitative visual assessment of stress perfusion images, with the ground truth stenosis label being defined by invasive Fractional Flow Reserve (FFR) and quantitative coronary angiography. Methods We used the Dan-NICAD 1 dataset, a multi-centre study with coronary computed tomography angiography, 1,5 T CMR stress perfusion, and invasive FFR available for a subset of 148 patients with suspected coronary artery disease. Image segmentation was performed by two independent readers. We used the Pyradiomics platform to extract radiomics first-order (n = 14) and texture (n = 75) features from the LV myocardium (basal, mid, apical) in rest and stress perfusion images. Results Overall, 92 patients (mean age 62 years, 56 men) were included in the study, 39 with positive FFR. We double-cross validated the model and, in each inner fold, we trained and validated a per territory model. The conventional analysis results reported sensitivity of 41% and specificity of 84%. Our final radiomics model demonstrated an improvement on these results with an average sensitivity of 53% and specificity of 86%. Conclusion In this proof-of-concept study from the Dan-NICAD dataset, we demonstrate the feasibility of radiomics analysis applied to CMR perfusion images with a suggestion of superior diagnostic performance of radiomics models over conventional visual analysis of perfusion images in picking up perfusion defects defined by invasive coronary angiography.
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Affiliation(s)
- Zahra Raisi-Estabragh
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Carlos Martin-Isla
- Dept. de Matematiques I Informatica, University of Barcelona, Barcelona, Spain
| | - Louise Nissen
- Department of Cardiology, Regionshospital Gødstrup, Herning, Denmark
| | - Liliana Szabo
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Victor M. Campello
- Dept. de Matematiques I Informatica, University of Barcelona, Barcelona, Spain
| | - Sergio Escalera
- Departament de Matemàtiques & Informàtica, Universitat de Barcelona, Barcelona, Spain
- Computer Vision Center, Univeritat Autònoma de Barcelona, Barcelona, Spain
| | - Simon Winther
- Department of Cardiology, Regionshospital Gødstrup, Herning, Denmark
| | - Morten Bøttcher
- Department of Cardiology, Regionshospital Gødstrup, Herning, Denmark
| | - Karim Lekadir
- Dept. de Matematiques I Informatica, University of Barcelona, Barcelona, Spain
| | - Steffen E. Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
- Health Data Research UK, London, United Kingdom
- Alan Turing Institute, London, United Kingdom
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Mittal TK, Hothi SS, Venugopal V, Taleyratne J, O'Brien D, Adnan K, Sehmi J, Daskalopoulos G, Deshpande A, Elfawal S, Sharma V, Shahin RA, Yuan M, Schlosshan D, Walker A, Abdel Rahman SED, Sunderji I, Wagh S, Chow J, Masood M, Sharma S, Agrawal S, Duraikannu C, McAlindon E, Mirsadraee S, Nicol ED, Kelion AD. The Use and Efficacy of FFR-CT: Real-World Multicenter Audit of Clinical Data With Cost Analysis. JACC Cardiovasc Imaging 2023; 16:1056-1065. [PMID: 37052559 DOI: 10.1016/j.jcmg.2023.02.005] [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: 01/17/2023] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Fractional flow reserve-computed tomography (FFR-CT) is endorsed by UK and U.S. chest pain guidelines, but its clinical effectiveness and cost benefit in real-world practice are unknown. OBJECTIVES The purpose of this study was to audit the use of FFR-CT in clinical practice against England's National Institute for Health and Care Excellence guidance and assess its diagnostic accuracy and cost. METHODS A multicenter audit was undertaken covering the 3 years when FFR-CT was centrally funded in England. For coronary computed tomographic angiograms (CCTAs) submitted for FFR-CT analysis, centers provided data on symptoms, CCTA and FFR-CT findings, and subsequent management. Audit standards included using FFR-CT only in patients with stable chest pain and equivocal stenosis (50%-69%). Diagnostic accuracy was evaluated against invasive FFR, when performed. Follow-up for nonfatal myocardial infarction and all-cause mortality was undertaken. The cost of an FFR-CT strategy was compared to alternative stress imaging pathways using cost analysis modeling. RESULTS A total of 2,298 CCTAs from 12 centers underwent FFR-CT analysis. Stable chest pain was the main symptom in 77%, and 40% had equivocal stenosis. Positive and negative predictive values of FFR-CT were 49% and 76%, respectively. A total of 46 events (2%) occurred over a mean follow-up period of 17 months; FFR-CT (cutoff: 0.80) was not predictive. The FFR-CT strategy costs £2,102 per patient compared with an average of £1,411 for stress imaging. CONCLUSIONS In clinical practice, the National Institute for Health and Care Excellence criteria for using FFR-CT were met in three-fourths of patients for symptoms and 40% for stenosis. FFR-CT had a low positive predictive value, making its use potentially more expensive than conventional stress imaging strategies.
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Affiliation(s)
- Tarun K Mittal
- Heart Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
| | - Sandeep S Hothi
- Heart and Lung Centre, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Vinod Venugopal
- Cardiology, United Lincolnshire Hospitals NHS Trust, Lincoln, United Kingdom
| | - John Taleyratne
- Cardiology, United Lincolnshire Hospitals NHS Trust, Lincoln, United Kingdom
| | - David O'Brien
- Cardiology, United Lincolnshire Hospitals NHS Trust, Lincoln, United Kingdom
| | - Kazi Adnan
- Cardiology, United Lincolnshire Hospitals NHS Trust, Lincoln, United Kingdom
| | - Joban Sehmi
- Cardiology, West Hertfordshire Hospitals NHS Trust, Watford, United Kingdom
| | | | - Aparna Deshpande
- Radiology, University Hospitals of Leicester, Leicester, United Kingdom
| | - Sara Elfawal
- Radiology, University Hospitals of Leicester, Leicester, United Kingdom
| | - Vinoda Sharma
- Cardiology, Sandwell and West Birmingham Hospital, Birmingham, United Kingdom
| | - Rajai A Shahin
- Cardiology, Sandwell and West Birmingham Hospital, Birmingham, United Kingdom
| | - Mengshi Yuan
- Cardiology, Sandwell and West Birmingham Hospital, Birmingham, United Kingdom
| | | | - Andrew Walker
- Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | - Imran Sunderji
- Cardiology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Sidhesh Wagh
- Cardiology, Hull University Teaching Hospitals, Hull, United Kingdom
| | - Jocelyn Chow
- Radiology, Newcastle upon Tyne Hospitals, Newcastle, United Kingdom
| | - Mohammed Masood
- Radiology, Newcastle upon Tyne Hospitals, Newcastle, United Kingdom
| | - Sumeet Sharma
- Cardiology, Ashford and St Peter's Hospitals, Surrey, United Kingdom
| | - Sharad Agrawal
- Cardiology, South Tyneside and Sunderland NHS Trust, Sunderland, United Kingdom
| | - Chary Duraikannu
- Radiology, Countess of Chester Hospital, Chester, United Kingdom
| | - Elisa McAlindon
- Heart and Lung Centre, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Saeed Mirsadraee
- Heart Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Edward D Nicol
- Heart Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' National Health Service (NHS) Foundation Trust, London, United Kingdom; School of Biomedical Engineering and Imaging Sciences, Kings College London, United Kingdom
| | - Andrew D Kelion
- Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Winther S, Dupont Rasmussen L, Westra J, Abdulzahra SRK, Dahl JN, Gormsen LC, Christiansen EH, Brix GS, Mortensen J, Ejlersen JA, Søndergaard HM, Hansson NCL, Holm NR, Knudsen LL, Eftekhari A, Møller PL, Rohde PD, Nyegaard M, Böttcher M. Danish study of Non-Invasive Testing in Coronary Artery Disease 3 (Dan-NICAD 3): study design of a controlled study on optimal diagnostic strategy. Open Heart 2023; 10:e002328. [PMID: 37487656 PMCID: PMC10373750 DOI: 10.1136/openhrt-2023-002328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Current guideline recommend functional imaging for myocardial ischaemia if coronary CT angiography (CTA) has shown coronary artery disease (CAD) of uncertain functional significance. However, diagnostic accuracy of selective myocardial perfusion imaging after coronary CTA is currently unclear. The Danish study of Non-Invasive testing in Coronary Artery Disease 3 trial is designed to evaluate head to head the diagnostic accuracy of myocardial perfusion imaging with positron emission tomography (PET) using the tracers 82Rubidium (82Rb-PET) compared with oxygen-15 labelled water PET (15O-water-PET) in patients with symptoms of obstructive CAD and a coronary CT scan with suspected obstructive CAD. METHODS AND ANALYSIS This prospective, multicentre, cross-sectional study will include approximately 1000 symptomatic patients without previous CAD. Patients are included after referral to coronary CTA. All patients undergo a structured interview and blood is sampled for genetic and proteomic analysis and a coronary CTA. Patients with possible obstructive CAD at coronary CTA are examined with both 82Rb-PET, 15O-water-PET and invasive coronary angiography with three-vessel fractional flow reserve and thermodilution measurements of coronary flow reserve. After enrolment, patients are followed with Seattle Angina Questionnaires and follow-up PET scans in patients with an initially abnormal PET scan and for cardiovascular events in 10 years. ETHICS AND DISSEMINATION Ethical approval was obtained from Danish regional committee on health research ethics. Written informed consent will be provided by all study participants. Results of this study will be disseminated via articles in international peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04707859.
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Affiliation(s)
- Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | | | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | | | | | - Jesper Mortensen
- Department of Nuclear Medicine, Gødstrup Hospital, Herning, Denmark
| | - June Anita Ejlersen
- Department of Nuclear Medicine, Regional Hospital Central Jutland, Viborg, Denmark
| | | | | | | | | | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Peter L Møller
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Palle Duun Rohde
- Department of Health, Science and Technology, Aalborg University, Aalborg, Denmark
| | - Mette Nyegaard
- Health Science and Technology, Aalborg Universitet, Gistrup, Denmark
| | - Morten Böttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
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10
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Groenhoff L, De Zan G, Costantini P, Siani A, Ostillio E, Carriero S, Muscogiuri G, Bergamaschi L, Patti G, Pizzi C, Sironi S, Pavon AG, Carriero A, Guglielmo M. The Non-Invasive Diagnosis of Chronic Coronary Syndrome: A Focus on Stress Computed Tomography Perfusion and Stress Cardiac Magnetic Resonance. J Clin Med 2023; 12:jcm12113793. [PMID: 37297986 DOI: 10.3390/jcm12113793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Coronary artery disease is still a major cause of death and morbidity worldwide. In the setting of chronic coronary disease, demonstration of inducible ischemia is mandatory to address treatment. Consequently, scientific and technological efforts were made in response to the request for non-invasive diagnostic tools with better sensitivity and specificity. To date, clinicians have at their disposal a wide range of stress-imaging techniques. Among others, stress cardiac magnetic resonance (S-CMR) and computed tomography perfusion (CTP) techniques both demonstrated their diagnostic efficacy and prognostic value in clinical trials when compared to other non-invasive ischemia-assessing techniques and invasive fractional flow reserve measurement techniques. Standardized protocols for both S-CMR and CTP usually imply the administration of vasodilator agents to induce hyperemia and contrast agents to depict perfusion defects. However, both methods have their own limitations, meaning that optimizing their performance still requires a patient-tailored approach. This review focuses on the characteristics, drawbacks, and future perspectives of these two techniques.
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Affiliation(s)
- Léon Groenhoff
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Giulia De Zan
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, 28100 Novara, Italy
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Pietro Costantini
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Agnese Siani
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Eleonora Ostillio
- Radiology Department, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Serena Carriero
- Postgraduate School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Giuseppe Muscogiuri
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy
- School of Medicine, University of Milano-Bicocca, 20900 Monza, Italy
| | - Luca Bergamaschi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Carmine Pizzi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Sandro Sironi
- School of Medicine, University of Milano-Bicocca, 20900 Monza, Italy
- Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Anna Giulia Pavon
- Cardiovascular Department, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | | | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, 2545 AA The Hague, The Netherlands
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11
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Banasik K, Møller PL, Techlo TR, Holm PC, Walters GB, Ingason A, Rosengren A, Rohde PD, Kogelman LJA, Westergaard D, Siggaard T, Chmura PJ, Chalmer MA, Magnússon ÓÞ, Þórisson GÁ, Stefánsson H, Guðbjartsson DF, Stefánsson K, Olesen J, Winther S, Bøttcher M, Brunak S, Werge T, Nyegaard M, Hansen TF. DanMAC5: a browser of aggregated sequence variants from 8,671 whole genome sequenced Danish individuals. BMC Genom Data 2023; 24:30. [PMID: 37244984 DOI: 10.1186/s12863-023-01132-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 05/18/2023] [Indexed: 05/29/2023] Open
Abstract
OBJECTIVES Allele counts of sequence variants obtained by whole genome sequencing (WGS) often play a central role in interpreting the results of genetic and genomic research. However, such variant counts are not readily available for individuals in the Danish population. Here, we present a dataset with allele counts for sequence variants (single nucleotide variants (SNVs) and indels) identified from WGS of 8,671 (5,418 females) individuals from the Danish population. The data resource is based on WGS data from three independent research projects aimed at assessing genetic risk factors for cardiovascular, psychiatric, and headache disorders. To enable the sharing of information on sequence variation in Danish individuals, we created summarized statistics on allele counts from anonymized data and made them available through the European Genome-phenome Archive (EGA, https://identifiers.org/ega. DATASET EGAD00001009756 ) and in a dedicated browser, DanMAC5 (available at www.danmac5.dk ). The summary level data and the DanMAC5 browser provide insight into the allelic spectrum of sequence variants segregating in the Danish population, which is important in variant interpretation. DATA DESCRIPTION Three WGS datasets with an average coverage of 30x were processed independently using the same quality control pipeline. Subsequently, we summarized, filtered, and merged allele counts to create a high-quality summary level dataset of sequence variants.
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Affiliation(s)
- Karina Banasik
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark.
| | - Peter L Møller
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, DK-8000, Aarhus C, Denmark
| | - Tanya R Techlo
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital, Valdemar Hansensvej 1-13, DK-2600, Glostrup, Denmark
| | - Peter C Holm
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark
| | | | - Andrés Ingason
- Institute for Biological Psychiatry, Mental Health Center Sct Hans, Copenhagen University Hospital, Boeserup vej 2, DK-4000, Roskilde, Denmark
| | - Anders Rosengren
- Institute for Biological Psychiatry, Mental Health Center Sct Hans, Copenhagen University Hospital, Boeserup vej 2, DK-4000, Roskilde, Denmark
| | - Palle D Rohde
- Department of Health Science and Technology, Genomic Medicine Group, Aalborg University, Selma Lagerløfs Vej 249, DK-9260, Gistrup, Denmark
| | - Lisette J A Kogelman
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital, Valdemar Hansensvej 1-13, DK-2600, Glostrup, Denmark
| | - David Westergaard
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark
| | - Troels Siggaard
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark
| | - Piotr J Chmura
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark
| | - Mona A Chalmer
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital, Valdemar Hansensvej 1-13, DK-2600, Glostrup, Denmark
| | | | | | | | | | | | - Jes Olesen
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital, Valdemar Hansensvej 1-13, DK-2600, Glostrup, Denmark
| | - Simon Winther
- Department of Cardiology, University Clinic for Cardiovascular Research, Gødstrup Hospital, Hospitalsvej 15, DK-7400, Herning, Denmark
| | - Morten Bøttcher
- Department of Cardiology, University Clinic for Cardiovascular Research, Gødstrup Hospital, Hospitalsvej 15, DK-7400, Herning, Denmark
| | - Søren Brunak
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark
| | - Thomas Werge
- Institute for Biological Psychiatry, Mental Health Center Sct Hans, Copenhagen University Hospital, Boeserup vej 2, DK-4000, Roskilde, Denmark
| | - Mette Nyegaard
- Department of Biomedicine, Aarhus University, Høegh-Guldbergsgade 10, DK-8000, Aarhus C, Denmark
- Department of Health Science and Technology, Genomic Medicine Group, Aalborg University, Selma Lagerløfs Vej 249, DK-9260, Gistrup, Denmark
| | - Thomas F Hansen
- Translational Disease Systems Biology, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200, Copenhagen N, Denmark
- Danish Headache Center, Department of Neurology, Copenhagen University Hospital, Valdemar Hansensvej 1-13, DK-2600, Glostrup, Denmark
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12
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Rasmussen LD, Winther S, Eftekhari A, Karim SR, Westra J, Isaksen C, Brix L, Ejlersen JA, Murphy T, Milidonis X, Nyegaard M, Benovoy M, Johansen JK, Søndergaard HM, Hammid O, Mortensen J, Knudsen LL, Gormsen LC, Christiansen EH, Chiribiri A, Petersen SE, Böttcher M. Second-Line Myocardial Perfusion Imaging to Detect Obstructive Stenosis: Head-to-Head Comparison of CMR and PET. JACC Cardiovasc Imaging 2023; 16:642-655. [PMID: 36881421 DOI: 10.1016/j.jcmg.2022.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/25/2022] [Accepted: 11/14/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND Guidelines recommend verification of myocardial ischemia by selective second-line myocardial perfusion imaging (MPI) following a coronary computed tomography angiography (CTA) with suspected obstructive coronary artery disease (CAD). Head-to-head data on the diagnostic performance of different MPI modalities in this setting are sparse. OBJECTIVES The authors sought to compare, head-to-head, the diagnostic performance of selective MPI by 3.0-T cardiac magnetic resonance (CMR) and 82rubidium positron emission tomography (RbPET) in patients with suspected obstructive stenosis at coronary CTA using invasive coronary angiography (ICA) with fractional flow reserve (FFR) as reference. METHODS Consecutive patients (n = 1,732, mean age: 59.1 ± 9.5, 57.2% men) referred for coronary CTA with symptoms suggestive of obstructive CAD were included. Patients with suspected stenosis were referred for both CMR and RbPET and subsequently ICA. Obstructive CAD was defined as FFR ≤0.80 or >90% diameter stenosis by visual assessment. RESULTS In total, 445 patients had suspected stenosis on coronary CTA. Of these, 372 patients completed both CMR, RbPET and subsequent ICA with FFR. Hemodynamically obstructive CAD was identified in 164 of 372 (44.1%) patients. Sensitivities for CMR and RbPET were 59% (95% CI: 51%-67%) and 64% (95% CI: 56%-71%); P = 0.21, respectively, and specificities 84% (95% CI: 78%-89%) and 89% (95% CI: 84%-93%]); P = 0.08, respectively. Overall accuracy was higher for RbPET compared with CMR (73% vs 78%; P = 0.03). CONCLUSIONS In patients with suspected obstructive stenosis at coronary CTA, CMR, and RbPET show similar and moderate sensitivities but high specificities compared with ICA with FFR. This patient group represents a diagnostic challenge with frequent mismatch between advanced MPI tests and invasive measurements. (Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 2 [Dan-NICAD 2]; NCT03481712).
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Affiliation(s)
- Laust Dupont Rasmussen
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Ashkan Eftekhari
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christin Isaksen
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways Silkeborg Regional Hospital, Denmark
| | - Lau Brix
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways Silkeborg Regional Hospital, Denmark; Department of Procurement and Biomedical Engineering, Region Midt, Aarhus C, Denmark
| | | | - Theodore Murphy
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom
| | - Xenios Milidonis
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | | | | | - Osama Hammid
- Department of Cardiology, Regional Hospital East Jutland, Randers, Denmark
| | - Jesper Mortensen
- Department of Nuclear Medicine, Gødstrup Hospital, Herning, Denmark
| | | | - Lars Christian Gormsen
- Department of Clinical Medicine, Aarhus University, Denmark; Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | | | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom; William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, United Kingdom
| | - Morten Böttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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13
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Bjerking LH, Winther S, Hansen KW, Galatius S, Böttcher M, Prescott E. Prediction models as gatekeepers for diagnostic testing in angina patients with suspected chronic coronary syndrome. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:630-639. [PMID: 35575616 DOI: 10.1093/ehjqcco/qcac025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/30/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
AIMS Assessment of pre-test probability (PTP) is an important gatekeeper when selecting patients for diagnostic testing for coronary artery disease (CAD). The 2019 European Society of Cardiology (ESC) guidelines recommend upgrading PTP based on clinical risk factors but provide no estimates of how these affect PTP. We aimed to validate two published PTP models in a contemporary low-CAD-prevalence cohort and compare with the ESC 2019 PTP. METHODS AND RESULTS Previously published basic and clinical prediction models and the ESC 2019 PTP were validated in 42 328 patients (54% women) ≥30 years old without previous CAD referred for cardiac computed tomography angiography in a region of Denmark from 2008 to 2017. Obstructive CAD prevalence was 8.8%. The ESC 2019 PTP and basic model included angina symptoms, sex, and age, while the clinical model added diabetes mellitus family history of CAD, and dyslipidaemia. Discrimination was good for all three models [area under the receiver operating curve (AUC) 0.76, 95% confidence interval (CI) (0.75-0.77), 0.74 (0.73-0.75), and 0.76 (0.75-0.76), respectively]. Using the clinically relevant low predicted probability ≤5% of CAD cut-off, the clinical and basic models were well calibrated, whereas the ESC 2019 PTP overestimated CAD prevalence. At a cut-off of ≤5%, the clinical model ruled out 36.2% more patients than the ESC 2019 PTP, n = 23 592 (55.7%) vs. n = 8 245 (19.5%), while missing 824 (22.2%) vs. 132 (3.6%) cases of obstructive CAD. CONCLUSION A prediction model for CAD including cardiovascular risk factors was successfully validated. Implementation of this model would reduce the need for diagnostic testing and serve as gatekeeper if accepting a watchful waiting strategy for one-fifth of the patients.
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Affiliation(s)
- Louise Hougesen Bjerking
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | - Kim Wadt Hansen
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Søren Galatius
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Morten Böttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
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14
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Weir-McCall JR, Williams MC, Wood A. One step closer to quantifying 'clinical likelihood' in pre-test probability. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:597-599. [PMID: 35776955 PMCID: PMC9442847 DOI: 10.1093/ehjqcco/qcac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Jonathan R Weir-McCall
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0QQ, UK
- Department of Radiology, Royal Papworth Hospital, Cambridge CB20QQ Cambridge, UK
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH8 9YL, UK
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh EH8 9YL, UK
| | - Angela Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0QQ, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge CB2 0QQ, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge CB2 0QQ, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge CB2 0QQ, UK
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15
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Kato T, Momose M, Uemura Y, Naya M, Matsumoto N, Hida S, Yamauchi T, Nakajima T, Suzuki E, Inoko M, Tamaki N. Association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan. J Cardiol 2022; 80:475-481. [PMID: 35835641 DOI: 10.1016/j.jjcc.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/06/2022] [Accepted: 06/12/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial. We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan. METHODS From the data of 2780 patients with stable angina who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referrednon-invasive imaging tests (Japanese Coronary-Angiography or Myocardial Imaging for Angina Pectoris Study), 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1year. RESULTS Patients with ≥10% myocardial ischemia (n=173) were less likely to be women than patients with <10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (6.9% vs. 1.8%, p<0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to <10% myocardial ischemia for MACEs remained significant [adjusted hazard ratio (95% confidence interval), 2.40 (1.09-5.26), p=0.029]. After adjusting including treatments, the risk of MACEs became insignificant between the ≥10% myocardial ischemia group and the <10% myocardial ischemia group [adjusted hazard ratio (95% confidence interval), 1.04 (0.45-2.45), p=0.92]. CONCLUSION The presence of ≥10% myocardial ischemia at diagnosis was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.
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Affiliation(s)
- Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Mitsuru Momose
- Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Science, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoya Matsumoto
- Department of Cardiovascular Medicine, Nihon University, Tokyo, Japan
| | - Satoshi Hida
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Takao Yamauchi
- Cardiovascular Medicine, JCHO Sagamino Hospital, Sagamihara, Japan
| | | | - Eriko Suzuki
- Department of Nuclear Medicine, Hokkaido University, Sapporo, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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16
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Rasmussen LD, Fordyce CB, Nissen L, Hill CL, Alhanti B, Hoffmann U, Udelson J, Bøttcher M, Douglas PS, Winther S. The PROMISE Minimal Risk Score Improves Risk Classification of Symptomatic Patients With Suspected CAD. JACC Cardiovasc Imaging 2022; 15:1442-1454. [DOI: 10.1016/j.jcmg.2022.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 12/11/2022]
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17
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Nørgaard BL, Sand NP, Jensen JM. Is CT-derived fractional flow reserve superior to ischaemia testing? Expert Rev Cardiovasc Ther 2022; 20:165-168. [PMID: 35345959 DOI: 10.1080/14779072.2022.2059466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- B L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - N P Sand
- Department of Cardiology, and Regional Health Research, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - J M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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18
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Sumin AN, Shcheglova AV. Assessment of Pre-test and Clinical Probability in the Diagnosis of Chronic Coronary Syndrome — What's New? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-02-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In the 2019 European Society of Cardiology (ESC) guidelines, the diagnostic algorithm for chronic coronary syndrome (CCS) was significantly changed, a significant revision of the pretest probability assessment scale (PTP) was made, an assessment of the clinical probability of obstructive coronary artery disease was proposed, the recommendations on the use of diagnostic tests in various groups of patients were updated. Such a radical change in approaches to the diagnosis of CCS raised many questions that had to be answered by further studies conducted in the past two years. The review provides data on the validation of the new PTP scale and the proposed assessment of the clinical probability of obstructive coronary artery disease, taking into account risk factors and with the additional inclusion of information on the calcium index of coronary arteries. The proposals of experts on new algorithms for the choice of non-invasive / invasive examination of this category of patients were also considered. Overall, the new PTV rating scale (ECS 2019) has been validated and validated in retrospective analyzes of cohort studies. The scale for assessing the clinical likelihood of obstructive coronary artery disease makes it possible to classify 3.8-5 times more patients as a low probability of coronary artery disease compared to the assessment of PTP alone. Assessment of the post-test probability of coronary artery disease does not allow to confirm the presence of obstructive lesion and was not used. The experts proposed new modifications of the diagnostic algorithm (with a detailed assessment of the clinical probability, as well as without taking it into account), which require verification in further studies. Therefore, it is advisable to conduct prospective studies to confirm the possibility of reducing the total number of non-invasive and invasive studies in patients with suspected coronary heart disease, as well as the safety of such a decrease in diagnostic procedures.
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Affiliation(s)
- A. N. Sumin
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - A. V. Shcheglova
- Research Institute for Complex Issues of Cardiovascular Diseases
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Lyu L, Pan J, Li D, Li X, Yang W, Dong M, Guo C, Lin P, Han Y, Liang Y, Sun J, Yu D, Zhang P, Zhang M. Knowledge of Hyperemic Myocardial Blood Flow in Healthy Subjects Helps Identify Myocardial Ischemia in Patients With Coronary Artery Disease. Front Cardiovasc Med 2022; 9:817911. [PMID: 35187130 PMCID: PMC8850642 DOI: 10.3389/fcvm.2022.817911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/14/2022] [Indexed: 11/27/2022] Open
Abstract
Backgrounds Dynamic CT myocardial perfusion imaging (CT-MPI) allows absolute quantification of myocardial blood flow (MBF). Although appealing, CT-MPI has not yet been widely applied in clinical practice, partly due to our relatively limited knowledge of CT-MPI. Knowledge of distribution and variability of MBF in healthy subjects helps in recognition of physiological and pathological states of coronary artery disease (CAD). Objectives To describe the distribution and normal range of hyperemic MBF in healthy subjects obtained by dynamic CT-MPI and validate whether it can accurately identify functional myocardial ischemia when the cut-off value of hyperemia MBF is set to the lower limit of the normal range. Materials and Methods Fifty-one healthy volunteers (age, 38 ± 12 years; 15 men) were prospectively recruited. Eighty patients (age, 58 ± 10 years; 55 men) with suspected or known CAD who underwent interventional coronary angiography (ICA) examinations were retrospectively recruited. Comprehensive CCTA + dynamic CT-MPI protocol was performed by the third – generation dual-source CT scanner. Invasive fractional flow reserve (FFR) measurements were performed in vessels with 30–90% diameter reduction. ICA/FFR was used as the reference standard for diagnosing functional ischemia. The normal range for the hyperemic MBF were defined as the mean ± 1.96 SD. The cut-off value of hyperemic MBF was set to the lower limit of the normal range. Results The global hyperemic MBF were 164 ± 24 ml/100 ml/min and 123 ± 26 ml/100 ml/min for healthy participants and patients. The normal range of the hyperemic MBF was 116–211 ml/100 ml/min. Of vessels with an ICA/FFR result (n = 198), 67 (34%) were functionally significant. In the per-vessel analysis, an MBF cutoff value of <116 ml/100 ml/min can identify myocardial ischemia with a diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 85.9% (170/198), 91.0% (61/67), 83.2 % (109/131), 73.5% (61/83), and 94.8% (109/115). CT-MPI showed good consistency with ICA/FFR in diagnosing functional ischemia, with a Cohen's kappa statistic of 0.7016 (95%CI, 0.6009 – 0.8023). Conclusion Recognizing hyperemic MBF in healthy subjects helps better understand myocardial ischemia in CAD patients.
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Affiliation(s)
- Lijuan Lyu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jichen Pan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dumin Li
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xinhao Li
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mei Dong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chenghu Guo
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peixin Lin
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yeming Han
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yongfeng Liang
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Junyan Sun
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dexin Yu
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Pengfei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Pengfei Zhang
| | - Mei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Mei Zhang
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20
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Westra J, Li Z, Rasmussen L, Winther S, Li G, Nissen L, Petersen S, Ejlersen J, Isaksen C, Gormsen L, Urbonaviciene G, Eftekhari A, Weng T, Qu X, Bøtker H, Christiansen EH, Holm NR, Bøttcher M, Tu S. One-step anatomic and function testing by cardiac CT versus second-line functional testing in symptomatic patients with coronary artery stenosis: head-to-head comparison of CT-derived fractional flow reserve and myocardial perfusion imaging. EUROINTERVENTION 2021; 17:576-583. [PMID: 33196446 PMCID: PMC9724926 DOI: 10.4244/eij-d-20-00905] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND CT-QFR is a novel coronary computed tomography angiography (CTA)-based method for on-site evaluation of patients with suspected obstructive coronary artery disease (CAD). AIMS We aimed to compare the diagnostic performance of CT-QFR with myocardial perfusion scintigraphy (MPS) and cardiovascular magnetic resonance (CMR) as second-line tests in patients with suspected obstructive CAD after coronary CTA. METHODS A paired analysis of CT-QFR and MPS or CMR, with an invasive FFR-based classification as reference standard was carried out. Symptomatic patients with >50% diameter stenosis on coronary CTA were randomised to MPS or CMR and referred for invasive coronary angiography. RESULTS The rate of coronary CTA not feasible for CT-QFR analysis was 17%. Paired patient-level data were available for 118 patients in the MPS group and 113 in the CMR group. Patient-level diagnostic accuracy was better for CT-QFR than for both MPS (82.2% [95% CI: 75.2-89.2] vs 70.3% [95% CI: 62.0-78.7], p=0.029) and CMR (77.0% [95% CI: 69.1-84.9] vs 65.5% [95% CI: 56.6-74.4], p=0.047). Following a positive coronary CTA and with the intention to diagnose, CT-QFR, CMR and MPS were equally suitable as rule-in and rule-out modalities. CONCLUSIONS The diagnostic performance of CT-QFR as a second-line test was at least similar to MPS and CMR for the evaluation of obstructive CAD in symptomatic patients presenting with ≥50% diameter stenosis on coronary CTA.
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Affiliation(s)
- Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark,School of Biochemical engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Zehang Li
- School of Biochemical engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Laust Rasmussen
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | - Simon Winther
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | - Guanyu Li
- School of Biochemical engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Louise Nissen
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | - Steffen Petersen
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom,William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom
| | - June Ejlersen
- Department of Nuclear Medicine, Hospital Unit West Jutland, Herning Denmark
| | - Christin Isaksen
- Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - Lars Gormsen
- Department of Nuclear Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ashkan Eftekhari
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tingwen Weng
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xinkai Qu
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Hans Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Morten Bøttcher
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | - Shengxian Tu
- Shanghai Jiao Tong University, Room 123, Med-X Research Institute, No. 1954 Hua Shan Road, Xuhui District, Shanghai 200030, China
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21
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Winther S, Andersen IT, Gormsen LC, Steffensen FH, Nielsen LH, Grove EL, Diederichsen ACP, Urbonaviciene G, Lambrechtsen J, Zaremba T, Elpert FP, Husain M, Zelechowski MW, Bøtker HE, Bøttcher M. Prognostic value of myocardial perfusion imaging after first-line coronary computed tomography angiography: A multi-center cohort study. J Cardiovasc Comput Tomogr 2021; 16:34-40. [PMID: 34475016 DOI: 10.1016/j.jcct.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/27/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Further diagnostic testing may be required after a coronary computed tomography angiography (CTA) showing suspected coronary stenosis. Whether myocardial perfusion imaging (MPI) provides further prognostic information post-CTA remains debated. We evaluated the prognosis for patients completing CTA stratified for post-CTA diagnostic work-up using real-world data. METHODS We identified all patients in our uptake area with angina symptoms undergoing first-time CTA over a 10-year period. Follow-up time was a median of 3.7 years [1.9-5.8]. The primary endpoint was a composite of myocardial infarction or death. The secondary endpoint was late revascularization. RESULTS During the study period 53,351 patients underwent CTA. Of these, 24% were referred for further down-stream testing, 3,547 (7%) to MPI and 9,135 (17%) to invasive coronary angiography (ICA). The primary and secondary endpoints occurred in 2,026 (3.8%) and 954 (1.8%) patients. Patient-characteristic-adjusted hazard ratios for the primary and secondary endpoint using patients with a normal CTA as reference were 1.37 (1.21-1.55) and 2.50 (1.93-3.23) for patient treated medically, 1.68 (1.39-2.03) and 6.13 (4.58-8.21) for patients referred to MPI and 1.94 (1.69-2.23) and 9.18 (7.16-11.78) for patients referred for ICA, respectively. Adjusted analysis with stratification for disease severity at CTA showed similar hazard ratios for patients treated medically after CTA and patients referred for MPI and treated medically after the MPI. CONCLUSION In patients completing coronary CTA, second-line MPI testing seems to identify patients at low risk of future events. MPI seems to have the potential to act as gatekeeper for ICA after coronary CTA.
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Affiliation(s)
- Simon Winther
- Department of Cardiology, Hospital Unit West, Herning, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | | | | | | | | | - Erik Lerkevang Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Denmark.
| | | | | | - Jess Lambrechtsen
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark.
| | - Tomas Zaremba
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Frank-Peter Elpert
- Department of Cardiology, Regional Hospital of South Jutland, Aabenraa, Denmark.
| | - Majed Husain
- Department of Cardiology, Regional Hospital of South West Denmark, Esbjerg, Denmark.
| | | | - Hans Erik Bøtker
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Denmark.
| | - Morten Bøttcher
- Department of Cardiology, Hospital Unit West, Herning, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
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22
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Christiansen MK, Winther S, Nissen L, Vilhjálmsson BJ, Frost L, Johansen JK, Møller PL, Schmidt SE, Westra J, Holm NR, Jensen HK, Christiansen EH, Guðbjartsson DF, Hólm H, Stefánsson K, Bøtker HE, Bøttcher M, Nyegaard M. Polygenic Risk Score-Enhanced Risk Stratification of Coronary Artery Disease in Patients With Stable Chest Pain. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2021; 14:e003298. [PMID: 34032468 DOI: 10.1161/circgen.120.003298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Polygenic risk scores (PRSs) are associated with coronary artery disease (CAD), but the clinical potential of using PRSs at the single-patient level for risk stratification has yet to be established. We investigated whether adding a PRS to clinical risk factors (CRFs) improves risk stratification in patients referred to coronary computed tomography angiography on a suspicion of obstructive CAD. METHODS In this prespecified diagnostic substudy of the Dan-NICAD trial (Danish study of Non-Invasive testing in Coronary Artery Disease), we included 1617 consecutive patients with stable chest symptoms and no history of CAD referred for coronary computed tomography angiography. CRFs used for risk stratification were age, sex, symptoms, prior or active smoking, antihypertensive treatment, lipid-lowering treatment, and diabetes. In addition, patients were genotyped, and their PRSs were calculated. All patients underwent coronary computed tomography angiography. Patients with a suspected ≥50% stenosis also underwent invasive coronary angiography with fractional flow reserve. A combined end point of obstructive CAD was defined as a visual invasive coronary angiography stenosis >90%, fractional flow reserve <0.80, or a quantitative coronary analysis stenosis >50% if fractional flow reserve measurements were not feasible. RESULTS The PRS was associated with obstructive CAD independent of CRFs (adjusted odds ratio, 1.8 [95% CI, 1.5-2.2] per SD). The PRS had an area under the curve of 0.63 (0.59-0.68), which was similar to that for age and sex. Combining the PRS with CRFs led to a CRF+PRS model with area under the curve of 0.75 (0.71-0.79), which was 0.04 more than the CRF model (P=0.0029). By using pretest probability (pretest probability) cutoffs at 5% and 15%, a net reclassification improvement of 15.8% (P=3.1×10-4) was obtained, with a down-classification of risk in 24% of patients (211 of 862) in whom the pretest probability was 5% to 15% based on CRFs alone. CONCLUSIONS Adding a PRS improved risk stratification of obstructive CAD beyond CRFs, suggesting a modest clinical potential of using PRSs to guide diagnostic testing in the contemporary clinical setting. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02264717.
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Affiliation(s)
- Morten Krogh Christiansen
- Department of Cardiology (M.K.C., J.W., N.R.H., H.K.J., E.H.C., H.E.B.), Aarhus University Hospital, Denmark.,Department of Internal Medicine, Horsens Regional Hospital, Denmark (M.K.C.)
| | - Simon Winther
- Department of Cardiology (S.W., M.B.), Hospital Unit West, Herning, Denmark
| | - Louise Nissen
- Department of Radiology (L.N.), Hospital Unit West, Herning, Denmark
| | | | - Lars Frost
- Department of Cardiology, Silkeborg Regional Hospital, Denmark (L.F., J.K.J.)
| | - Jane Kirk Johansen
- Department of Cardiology, Silkeborg Regional Hospital, Denmark (L.F., J.K.J.)
| | - Peter Loof Møller
- Department of Biomedicine (P.L.M., M.N.), Aarhus University, Denmark
| | - Samuel Emil Schmidt
- Department of Health Science and Technology, Aalborg University, Denmark (S.E.S., M.N.)
| | - Jelmer Westra
- Department of Cardiology (M.K.C., J.W., N.R.H., H.K.J., E.H.C., H.E.B.), Aarhus University Hospital, Denmark
| | - Niels Ramsing Holm
- Department of Cardiology (M.K.C., J.W., N.R.H., H.K.J., E.H.C., H.E.B.), Aarhus University Hospital, Denmark
| | - Henrik Kjærulf Jensen
- Department of Cardiology (M.K.C., J.W., N.R.H., H.K.J., E.H.C., H.E.B.), Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Faculty of Health (H.K.J., H.E.B.), Aarhus University, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology (M.K.C., J.W., N.R.H., H.K.J., E.H.C., H.E.B.), Aarhus University Hospital, Denmark
| | | | - Hilma Hólm
- deCODE Genetics/Amgen, Inc, Reykjavik, Iceland (D.F.G., H.H., K.S.)
| | - Kári Stefánsson
- deCODE Genetics/Amgen, Inc, Reykjavik, Iceland (D.F.G., H.H., K.S.)
| | - Hans Erik Bøtker
- Department of Cardiology (M.K.C., J.W., N.R.H., H.K.J., E.H.C., H.E.B.), Aarhus University Hospital, Denmark.,Department of Clinical Medicine, Faculty of Health (H.K.J., H.E.B.), Aarhus University, Denmark
| | - Morten Bøttcher
- Department of Cardiology (S.W., M.B.), Hospital Unit West, Herning, Denmark
| | - Mette Nyegaard
- Department of Clinical Genetics (M.N.), Aarhus University Hospital, Denmark.,Department of Biomedicine (P.L.M., M.N.), Aarhus University, Denmark.,Department of Health Science and Technology, Aalborg University, Denmark (S.E.S., M.N.)
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23
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Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman DS, Blankstein R, Leipsic J, Newby D, Nicol ED, Nieman K, Shaw L, Villines TC, Williams M, Hecht HS. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021; 15:192-217. [PMID: 33303384 PMCID: PMC8713482 DOI: 10.1016/j.jcct.2020.11.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Y Chandrashekhar
- University of Minnesota and VA Medical Center, Minneapolis, MN, USA
| | - Amir Ahmadi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suhny Abbara
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Ron Blankstein
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - David Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Edward D Nicol
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Leslee Shaw
- New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | - Michelle Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Harvey S Hecht
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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24
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Møller PL, Rohde PD, Winther S, Breining P, Nissen L, Nykjaer A, Bøttcher M, Nyegaard M, Kjolby M. Sortilin as a Biomarker for Cardiovascular Disease Revisited. Front Cardiovasc Med 2021; 8:652584. [PMID: 33937362 PMCID: PMC8085299 DOI: 10.3389/fcvm.2021.652584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Genetic variants in the genomic region containing SORT1 (encoding the protein sortilin) are strongly associated with cholesterol levels and the risk of coronary artery disease (CAD). Circulating sortilin has therefore been proposed as a potential biomarker for cardiovascular disease. Multiple studies have reported association between plasma sortilin levels and cardiovascular outcomes. However, the findings are not consistent across studies, and most studies have small sample sizes. The aim of this study was to evaluate sortilin as a biomarker for CAD in a well-characterized cohort with symptoms suggestive of CAD. In total, we enrolled 1,173 patients with suspected stable CAD referred to coronary computed tomography angiography. Sortilin was measured in plasma using two different technologies for quantifying circulating sortilin: a custom-made enzyme-linked immunosorbent assay (ELISA) and OLINK Cardiovascular Panel II. We found a relative poor correlation between the two methods (correlation coefficient = 0.21). In addition, genotyping and whole-genome sequencing were performed on all patients. By whole-genome regression analysis of sortilin levels measured with ELISA and OLINK, two independent cis protein quantitative trait loci (pQTL) on chromosome 1p13.3 were identified, with one of them being a well-established risk locus for CAD. Incorporating rare genetic variants from whole-genome sequence data did not identify any additional pQTLs for plasma sortilin. None of the traditional CAD risk factors, such as sex, age, smoking, and statin use, were associated with plasma sortilin levels. Furthermore, there was no association between circulating sortilin levels and coronary artery calcium score (CACS) or disease severity. Sortilin did not improve discrimination of obstructive CAD, when added to a clinical pretest probability (PTP) model for CAD. Overall, our results indicate that studies using different methodologies for measuring circulating sortilin should be compared with caution. In conclusion, the well-known SORT1 risk locus for CAD is linked to lower sortilin levels in circulation, measured with ELISA; however, the effect sizes are too small for sortilin to be a useful biomarker for CAD in a clinical setting of low- to intermediate-risk chest-pain patients.
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Affiliation(s)
| | - Palle D. Rohde
- Department of Chemistry and Bioscience, Aalborg University, Aalborg, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, NIDO, Herning, Denmark
| | - Peter Breining
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- PROMEMO and DANDRITE, Aarhus University, Aarhus, Denmark
| | - Louise Nissen
- Department of Cardiology, Gødstrup Hospital, NIDO, Herning, Denmark
| | - Anders Nykjaer
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- PROMEMO and DANDRITE, Aarhus University, Aarhus, Denmark
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, NIDO, Herning, Denmark
| | - Mette Nyegaard
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Mads Kjolby
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- PROMEMO and DANDRITE, Aarhus University, Aarhus, Denmark
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
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25
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Winther S, Nissen L, Schmidt SE, Westra J, Andersen IT, Nyegaard M, Madsen LH, Knudsen LL, Urbonaviciene G, Larsen BS, Struijk JJ, Frost L, Holm NR, Christiansen EH, Bøtker HE, Bøttcher M. Advanced heart sound analysis as a new prognostic marker in stable coronary artery disease. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 2:279-289. [PMID: 36712398 PMCID: PMC9707929 DOI: 10.1093/ehjdh/ztab031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/22/2021] [Accepted: 03/17/2021] [Indexed: 02/01/2023]
Abstract
Aims Recent technological advances enable diagnosing of obstructive coronary artery disease (CAD) from heart sound analysis with a high negative predictive value. However, the prognostic impact of this approach remains unknown. To investigate the prognostic value of heart sound analysis as two scores, the Acoustic-score and the CAD-score, in patients with suspected CAD which is treated according to standard of care. Methods and results Consecutive patients with angina symptoms referred for coronary computed tomography angiography (CTA) were enrolled. The Acoustic-score was developed from eight acoustic CAD-related features. This score was combined with risk factors to generate the CAD-score. A cut-off score >20 was pre-specified for both scores to indicate disease. If coronary CTA raised suspicion of obstructive CAD, patients were referred to invasive angiography and revascularized when indicated. Of 1675 enrolled patients, 1464 (87.4%) were included in this substudy. The combined primary endpoint was all-cause mortality and myocardial infarction (n = 26). Follow-up was 3.1 (2.7-3.4) years. Of patients with primary endpoints, the Acoustic-score was >20 in 25 (96%); the CAD-score was >20 in 22 (85%). In an unadjusted Cox analysis of the primary endpoints, the hazard ratio for scores >20 under current standard clinical care was 12.6 (1.7-93.2) for the Acoustic-score and 5.4 (1.9-15.7) for the CAD-score. The CAD-score contained prognostic information even after adjusting for lipid-lowering therapy initiation, stenosis at CTA, and early revascularization. Conclusion Heart sound analysis seems to carry prognostic information and may improve initial risk stratification of patients with suspected CAD. Clinicaltrialsorg ID NCT02264717.
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Affiliation(s)
- Simon Winther
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark,Corresponding author. Tel: 78430000,
| | - Louise Nissen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark
| | - Samuel Emil Schmidt
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7D, 9220 Aalborg, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Ina Trolle Andersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Mette Nyegaard
- Department of Biomedicine, Aarhus University, Høegh-Guldbergs Gade 10, 8000 Aarhus, Denmark
| | - Lene Helleskov Madsen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark
| | - Lars Lyhne Knudsen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark
| | - Grazina Urbonaviciene
- Department of Cardiology, Regional Hospital Central Jutland, Falkevej 1A, 8600 Silkeborg, Denmark
| | - Bjarke Skogstad Larsen
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7D, 9220 Aalborg, Denmark
| | - Johannes Jan Struijk
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7D, 9220 Aalborg, Denmark
| | - Lars Frost
- Department of Cardiology, Regional Hospital Central Jutland, Falkevej 1A, 8600 Silkeborg, Denmark
| | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, 7400 Herning, Denmark
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Therkildsen J, Winther S, Nissen L, Jørgensen HS, Thygesen J, Ivarsen P, Frost L, Isaksen C, Langdahl BL, Hauge EM, Böttcher M. Sex Differences in the Association Between Bone Mineral Density and Coronary Artery Disease in Patients Referred for Cardiac Computed Tomography. J Clin Densitom 2021; 24:55-66. [PMID: 31668962 DOI: 10.1016/j.jocd.2019.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 12/13/2022]
Abstract
Atherosclerosis and osteoporosis are both common and preventable diseases. Evidence supports a link between coronary artery disease (CAD) and low bone mineral density (BMD). This study aimed to assess the association between thoracic spine BMD and CAD in men and women with symptoms suggestive of CAD. This cross-sectional study included 1487 (mean age 57 years (range 40-80), 47% men) patients referred for cardiac computed tomography (CT). Agatston coronary artery calcium score (CACS), CAD severity (no, mild, moderate, and severe), vessel involvement (no, 1-, 2-, and 3/left main disease), and invasive measurements were evaluated. BMD of three thoracic vertebrae was measured using quantitative CT. We used the American college of radiology cut-off values for lumbar spine BMD to categorize patients into very low (<80 mg/cm3), low (80-120 mg/cm3), or normal BMD (>120 mg/cm3). BMD as a continuous variable was included in the linear regression analyses to assess associations between CACS (CACS=0, CACS 1- 399, and CACS ≥ 400) and BMD, and CAD severity and BMD. Significant lower BMD was present with increasing CACS and stenosis degree unadjusted. Multivariate linear regression analyses in women revealed a significant correlation between BMD and CACS groups (β = -4.06, p<0.05), but no correlation between BMD and CAD severity (β = -1.59, p = 0.14). No association was found between BMD and CACS (β = -1.50, p = 0.36) and CAD severity (β = 0.07, p = 0.94) in men. BMD is significantly correlated to CACS after adjusting for confounders in women, but not in men, suggesting a possible sex difference in pathophysiology.
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Affiliation(s)
| | - Simon Winther
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Louise Nissen
- Department of Cardiology, Hospital Unit West, Herning, Denmark
| | | | - Jesper Thygesen
- Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark
| | - Per Ivarsen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Frost
- Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - Christin Isaksen
- Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ellen-Margrethe Hauge
- Departments of Rheumatology, Aarhus University Hospital, and Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Morten Böttcher
- Department of Cardiology, Hospital Unit West, Herning, Denmark
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27
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Winther S, Schmidt SE, Mayrhofer T, Bøtker HE, Hoffmann U, Douglas PS, Wijns W, Bax J, Nissen L, Lynggaard V, Christiansen JJ, Saraste A, Bøttcher M, Knuuti J. Incorporating Coronary Calcification Into Pre-Test Assessment of the Likelihood of Coronary Artery Disease. J Am Coll Cardiol 2020; 76:2421-2432. [DOI: 10.1016/j.jacc.2020.09.585] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 01/17/2023]
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28
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de Knegt MC, Rossi A, Petersen SE, Wragg A, Khurram R, Westwood M, Saberwal B, Mathur A, Nieman K, Bamberg F, Jensen MT, Pugliese F. Stress myocardial perfusion with qualitative magnetic resonance and quantitative dynamic computed tomography: comparison of diagnostic performance and incremental value over coronary computed tomography angiography. Eur Heart J Cardiovasc Imaging 2020:jeaa270. [PMID: 33029616 DOI: 10.1093/ehjci/jeaa270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/23/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS Assessment of haemodynamically significant coronary artery disease (CAD) using cardiovascular magnetic resonance (CMR) imaging perfusion or dynamic stress myocardial perfusion imaging by computed tomography (CT perfusion) may aid patient selection for invasive coronary angiography (ICA). We evaluated the diagnostic performance and incremental value of qualitative CMR perfusion and quantitative CT perfusion complementary to cardiac computed tomography angiography (CCTA) for the diagnosis of haemodynamically significant CAD using fractional flow reserve (FFR) and quantitative coronary angiography (QCA) as reference standard. METHODS AND RESULTS CCTA, qualitative visual CMR perfusion, visual CT perfusion, and quantitative relative myocardial blood flow (CT-MBF) were performed in patients with stable angina pectoris. FFR was measured in coronary vessels with stenosis visually estimated between 30% and 90% diameter reduction on ICA. Haemodynamically significant CAD was defined as FFR <0.80, or QCA ≥80% in those cases where FFR could not be performed. A total of 218 vessels from 93 patients were assessed. An optimal cut-off of 0.72 for relative CT-MBF was determined. The diagnostic performances (area under the receiver-operating characteristics curves, 95% CI) of visual CMR perfusion (0.84, 0.77-0.90) and relative CT-MBF (0.86, 0.81-0.92) were comparable and outperformed visual CT perfusion (0.64, 0.57-0.71). In combination with CCTA ≥50%, CCTA + visual CMR perfusion (0.91, 0.86-0.96), CCTA + relative CT-MBF (0.92, 0.88-0.96), and CCTA + visual CT perfusion (0.82, 0.75-0.90) improved discrimination compared with CCTA alone (all P < 0.05). CONCLUSION Visual CMR perfusion and relative CT-MBF outperformed visual CT perfusion and provided incremental discrimination compared with CCTA alone for the diagnosis of haemodynamically significant CAD.
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Affiliation(s)
- Martina C de Knegt
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Alexia Rossi
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Steffen E Petersen
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Andrew Wragg
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Ruhaid Khurram
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Mark Westwood
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Bunny Saberwal
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Anthony Mathur
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Magnus T Jensen
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Francesca Pugliese
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts NIHR Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
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Validation and update of the minimal risk tool in patients suspected of chronic coronary syndrome. Int J Cardiovasc Imaging 2020; 37:699-706. [PMID: 32875484 DOI: 10.1007/s10554-020-01982-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/24/2020] [Indexed: 01/03/2023]
Abstract
Risk stratification in patients with suspected coronary artery disease (CAD) is important. Recently, the minimal-risk-tool (MRT) was developed to identify individuals with low CAD risk despite symptoms in order to avoid unnecessary testing. We aimed to validate and update the MRT-model in a contemporary cohort. The Dan-NICAD trial cohort, consisting of 1675 consecutive patients referred for coronary computed tomography angiography (CTA), was used to calculate the MRT-score based on the published fitted variable coefficients from the PROMISE and SCOT-HEART trials. Minimal risk was defined as zero calcium score, no coronary atherosclerosis at coronary CTA, and no cardiovascular events in the follow-up period. We tested an updated MRT-model by pooling the fitted variable coefficients from all three trials. A total of 1544 patients fulfilling the inclusion criteria were followed for 3.1 [2.7-3.4] years. In 710 (46%) patients, the criteria for minimal risk were fulfilled. Despite substantial coefficient variation, the MRTs based on the PROMISE, the SCOT-HEART and the updated MRT variables showed similar moderate to high discriminative performance for minimal risk estimation. Although all three models tended to underestimate minimal risk, the updated MRT had the best performance. Using a 75% minimal risk cut-off, the updated MRT showed a sensitivity of 11.6% (95% CI 9.3-14.2%) and specificity of 99.3% (95% CI 98.6-99.8%). An updated MRT model based on three large studies increased calibration compared to the existing MRT models, whereas discrimination was similar despite substantial coefficient variation. The updated MRT might supplement currently recommended pre-test probability models.
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van Diemen PA, Schumacher SP, Driessen RS, Bom MJ, Stuijfzand WJ, Everaars H, de Winter RW, Raijmakers PG, van Rossum AC, Hirsch A, Danad I, Knaapen P. Coronary computed tomography angiography and [ 15O]H 2O positron emission tomography perfusion imaging for the assessment of coronary artery disease. Neth Heart J 2020; 28:57-65. [PMID: 32780333 PMCID: PMC7419408 DOI: 10.1007/s12471-020-01445-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Determining the anatomic severity and extent of coronary artery disease (CAD) by means of coronary computed tomography angiography (CCTA) and its effect on perfusion using myocardial perfusion imaging (MPI) form the pillars of the non-invasive imaging assessment of CAD. This review will 1) focus on CCTA and [15O]H2O positron emission tomography MPI as stand-alone imaging modalities and their combined use for detecting CAD, 2) highlight some of the lessons learned from the PACIFIC trial (Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve (FFR) (NCT01521468)), and 3) discuss the use of [15O]H2O PET MPI in the clinical work-up of patients with a chronic coronary total occlusion (CTO).
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Affiliation(s)
- P A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - S P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R S Driessen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M J Bom
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - W J Stuijfzand
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H Everaars
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - P G Raijmakers
- Department of Radiology, Nuclear Medicine and PET research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A Hirsch
- Department of Cardiology and Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - I Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - P Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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31
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Therkildsen J, Nissen L, Jørgensen HS, Thygesen J, Ivarsen P, Frost L, Isaksen C, Langdahl BL, Hauge EM, Boettcher M, Winther S. Thoracic Bone Mineral Density Derived from Cardiac CT Is Associated with Greater Fracture Rate. Radiology 2020; 296:499-508. [PMID: 32662758 DOI: 10.1148/radiol.2020192706] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Osteoporosis is a prevalent, under-diagnosed, and treatable disease associated with increased fracture risk. Bone mineral density (BMD) derived from cardiac CT may be used to determine fracture rate. Purpose To assess the association between fracture rate and thoracic BMD derived from cardiac CT. Materials and Methods This prospective cohort study included consecutive participants referred for cardiac CT for evaluation of ischemic heart disease between September 2014 and March 2016. End of follow-up was June 30, 2018. In all participants, volumetric BMD of three thoracic vertebrae was measured by using quantitative CT software. The primary and secondary outcomes were any incident fracture and any incident osteoporosis-related fracture registered in the National Patient Registry, respectively. Hazard ratios were assessed by using BMD categorized as very low (<80 mg/cm3), low (80-120 mg/cm3), or normal (>120 mg/cm3). The study is registered at ClinicalTrials.gov (identifier: NCT02264717). Results In total, 1487 participants (mean age, 57 years ± 9; age range, 40-80 years; 52.5% women) were included, of whom 179 (12.0%) had very low BMD. During follow-up (median follow-up, 3.1 years; interquartile range, 2.7-3.4 years; range, 0.2-3.8 years), 80 of 1487 (5.3%) participants were diagnosed with an incident fracture and in 31 of 80 participants, the fracture was osteoporosis related. In unadjusted Cox regressions analyses, very low BMD was association with a greater rate of any fracture (hazard ratio, 2.6; 95% confidence interval [CI]: 1.4, 4.7; P = .002) and any osteoporosis-related fracture (hazard ratio, 8.1; 95% CI: 2.4, 26.7; P = .001) compared with normal BMD. After adjusting for age and sex, very low BMD remained associated with any fracture (hazard ratio, 2.1; 95% CI: 1.1, 4.2) and any osteoporosis-related fracture (hazard ratio, 4.0; 95% CI: 1.1, 14.6). Conclusion Routine cardiac CT can be used to help measure thoracic bone mineral density (BMD) to identify individuals who have low BMD and a greater fracture rate. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Bredella in this issue.
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Affiliation(s)
- Josephine Therkildsen
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Louise Nissen
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Hanne S Jørgensen
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Jesper Thygesen
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Per Ivarsen
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Lars Frost
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Christin Isaksen
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Bente L Langdahl
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Ellen-Margrethe Hauge
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Morten Boettcher
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
| | - Simon Winther
- From the Department of Cardiology, Hospital Unit West, Gl.landevej 61, Herning 7400, Denmark (J. Therkildsen, L.N., M.B., S.W.); Laboratory of Nephrology, Department of Immunology and Microbiology, KU Leuven-University of Leuven, Belgium (H.S.J.); Department of Clinical Engineering, Aarhus University Hospital, Aarhus, Denmark (J. Thygesen); Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark (P.I.); Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark (L.F.); Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark (C.I.); Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark (B.L.L.); Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark (E.M.H., H.S.J.); and Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark (S.W.)
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Ullah W, Roomi S, Abdullah HM, Mukhtar M, Ali Z, Ye P, Haas DC, Figueredo VM. Diagnostic Accuracy of Cardiac Magnetic Resonance Versus Fractional Flow Reserve: A Systematic Review and Meta-Analysis. Cardiol Res 2020; 11:145-154. [PMID: 32494324 PMCID: PMC7239594 DOI: 10.14740/cr1028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023] Open
Abstract
Background Fractional flow reserve (FFR) is considered the gold standard for diagnosis of coronary artery disease (CAD). Stress Cardiac magnetic resonance (SCMR) has been recently gaining traction as a non-invasive alternative to FFR. Methods Studies comparing the diagnostic accuracy of SCMR versus FFR were identified and analyzed using Review Manager (RevMan) 5.3 and Stata software. Results A total of 28 studies, comprising 2,387 patients, were included. The pooled sensitivity and specificity for SCMR were 86% and 86% at the patient level, and 82% and 88% at the vessel level, respectively. When the patient-level data were stratified based on the FFR thresholds, higher sensitivity and specificity (both 90%) were noted with the higher cutoff (0.75) and lower cutoff (0.8), respectively. At the vessel level, sensitivity and specificity at the lower FFR threshold were significantly higher at 88% and 89%, compared to the corresponding values for higher cutoff at 0.75. Similarly, meta-regression analysis of SCMR at higher (3T) resolution showed a higher sensitivity of 87% at the patient level and higher specificity of 90% at the vessel level. The highest sensitivity and specificity of SCMR (92% and 94%, respectively) were noted in studies with CAD prevalence greater than 60%. Conclusions SCMR has high diagnostic accuracy for CAD comparable to FFR at a spatial resolution of 3T and an FFR cut-off of 0.80. An increase in CAD prevalence further improved the specificity of SCMR.
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Affiliation(s)
- Waqas Ullah
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Sohaib Roomi
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Hafez M Abdullah
- Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Maryam Mukhtar
- Internal Medicine, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Zain Ali
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Ping Ye
- Internal Medicine, University of South Dakota, Sioux Falls, SD, USA.,Avera Research Institute, Avera Health, Sioux Falls, SD, USA
| | - Donald C Haas
- Abington Hospital-Jefferson Health, Abington, PA, USA
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van Diemen PA, Driessen RS, Kooistra RA, Stuijfzand WJ, Raijmakers PG, Boellaard R, Schumacher SP, Bom MJ, Everaars H, de Winter RW, van de Ven PM, Reiber JH, Min JK, Leipsic JA, Knuuti J, Underwood RS, van Rossum AC, Danad I, Knaapen P. Comparison Between the Performance of Quantitative Flow Ratio and Perfusion Imaging for Diagnosing Myocardial Ischemia. JACC Cardiovasc Imaging 2020; 13:1976-1985. [PMID: 32305469 DOI: 10.1016/j.jcmg.2020.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/12/2019] [Accepted: 02/05/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study compared the performance of the quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) myocardial perfusion imaging (MPI) for the diagnosis of fractional flow reserve (FFR)-defined coronary artery disease (CAD). BACKGROUND QFR estimates FFR solely based on cine contrast images acquired during invasive coronary angiography (ICA). Head-to-head studies comparing QFR with noninvasive MPI are lacking. METHODS A total of 208 (624 vessels) patients underwent technetium-99m tetrofosmin SPECT and [15O]H2O PET imaging before ICA in conjunction with FFR measurements. ICA was obtained without using a dedicated QFR acquisition protocol, and QFR computation was attempted in all vessels interrogated by FFR (552 vessels). RESULTS QFR computation succeeded in 286 (52%) vessels. QFR correlated well with invasive FFR overall (R = 0.79; p < 0.001) and in the subset of vessels with an intermediate (30% to 90%) diameter stenosis (R = 0.76; p < 0.001). Overall, per-vessel analysis demonstrated QFR to exhibit a superior sensitivity (70%) in comparison with SPECT (29%; p < 0.001), whereas it was similar to PET (75%; p = 1.000). Specificity of QFR (93%) was higher than PET (79%; p < 0.001) and not different from SPECT (96%; p = 1.000). As such, the accuracy of QFR (88%) was superior to both SPECT (82%; p = 0.010) and PET (78%; p = 0.004). Lastly, the area under the receiver operating characteristics curve of QFR, in the overall sample (0.94) and among vessels with an intermediate lesion (0.90) was higher than SPECT (0.63 and 0.61; p < 0.001 for both) and PET (0.82; p < 0.001 and 0.77; p = 0.002), respectively. CONCLUSIONS In this head-to-head comparative study, QFR exhibited a higher diagnostic value for detecting FFR-defined significant CAD compared with perfusion imaging by SPECT or PET.
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Affiliation(s)
- Pepijn A van Diemen
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Roel S Driessen
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Wynand J Stuijfzand
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ronald Boellaard
- Department of Radiology, Nuclear Medicine, and PET Research, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan P Schumacher
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel J Bom
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Henk Everaars
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ruben W de Winter
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - James K Min
- Institute for Cardiovascular Imaging, Weill-Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Jonathan A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Richard S Underwood
- Department of Nuclear Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Albert C van Rossum
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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Christiansen MK, Nissen L, Winther S, Møller PL, Frost L, Johansen JK, Jensen HK, Guðbjartsson D, Holm H, Stefánsson K, Bøtker HE, Bøttcher M, Nyegaard M. Genetic Risk of Coronary Artery Disease, Features of Atherosclerosis, and Coronary Plaque Burden. J Am Heart Assoc 2020; 9:e014795. [PMID: 31983321 PMCID: PMC7033858 DOI: 10.1161/jaha.119.014795] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Polygenic risk scores (PRSs) based on risk variants from genome‐wide association studies predict coronary artery disease (CAD) risk. However, it is unknown whether the PRS is associated with specific CAD characteristics. Methods and Results We consecutively included 1645 patients with suspected stable CAD undergoing coronary computed tomography angiography. A multilocus PRS was calculated as the weighted sum of CAD risk variants. Plaques were evaluated using an 18‐segment model and characterized by stenosis severity and composition (soft [0%‐19% calcified], mixed‐soft [20%‐49% calcified], mixed‐calcified [50%‐79% calcified], or calcified [≥80% calcified]). Coronary artery calcium score and segment stenosis score were used to characterize plaque burden. For each standard deviation increase in the PRS, coronary artery calcium score increased by 78% (P=4.1e‐26) and segment stenosis score increased by 16% (P=2.4e‐29) in the fully adjusted model. The PRS was associated with a higher prevalence of obstructive plaques (odds ratio [OR]: 1.78, P=5.6e‐16), calcified (OR: 1.69, P=6.5e‐17), mixed‐calcified (OR: 1.67, P=7.3e‐9), mixed‐soft (OR: 1.45, P=1.6e‐6), and soft plaques (OR: 1.49, P=2.5e‐6), and a higher prevalence of plaque in each coronary vessel (all P<1.0e‐4). However, when analyzing data on a plaque level (3007 segments with plaque in 849 patients) the PRS was not associated with stenosis severity, plaque composition, or localization (all P>0.05). Conclusions Our results suggest that polygenic risk based on large genome‐wide association studies increases CAD risk through an increased burden of coronary atherosclerosis rather than promoting specific plaque features. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02264717.
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Affiliation(s)
- Morten Krogh Christiansen
- Department of Cardiology Aarhus University Hospital Aarhus Denmark.,Department of Internal Medicine Horsens Regional Hospital Horsens Denmark
| | - Louise Nissen
- Department of Cardiology Hospital Unit West Herning Denmark
| | - Simon Winther
- Department of Cardiology Aarhus University Hospital Aarhus Denmark.,Department of Cardiology Hospital Unit West Herning Denmark
| | | | - Lars Frost
- Department of Cardiology Silkeborg Regional Hospital Silkeborg Denmark
| | | | | | | | - Hilma Holm
- deCODE Genetics/Amgen, Inc. Reykjavik Iceland
| | | | - Hans Erik Bøtker
- Department of Cardiology Aarhus University Hospital Aarhus Denmark
| | | | - Mette Nyegaard
- Department of Biomedicine Aarhus University Aarhus Denmark
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de Thurah A, Andersen IT, Tinggaard AB, Riis AH, Therkildsen J, Bøtker HE, Bøttcher M, Hauge EM. Risk of major adverse cardiovascular events among patients with rheumatoid arthritis after initial CT-based diagnosis and treatment. RMD Open 2020; 6:e001113. [PMID: 31958282 PMCID: PMC6999677 DOI: 10.1136/rmdopen-2019-001113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is a known risk factor for developing coronary artery disease (CAD). The influence of RA on the prognosis after initial CAD diagnosis and treatment is however largely unknown. We examined the risk of major cardiovascular events among RA and non-RA patients with chest pain referred to cardiac CT. METHODS This was a follow-up study, using data from the Western Denmark Heart Registry, containing data on CT angiography examinations (Cardiac CT). Information on RA diagnosis and covariates were identified through nationwide administrative registers. The primary outcome was a combined outcome including, myocardial infarction, ischaemic or unspecified stroke, coronary artery bypass grafting, percutaneous coronary intervention, and all-cause mortality. Median time until events or censoring was 3.5 years (min/max: 0.0: 9.2). Cox proportional hazard models were used to examine the association between RA/non-RA patients and outcomes. RESULTS Among 42 257 patients, referred between 2008 and 2016, we identified 358 (0.8%) with RA. An increased risk was seen in RA compared with non-RA (adjusted HR 1.35, 95% CI 0.93 to 1.96). Among patients who had received flare treatment more than once prior to cardiac CT the adjusted HR 1.80 (95% CI 1.08 to 3.00), and among patients with seropositive RA the adjusted HR 1.42 (95% CI 0.93 to 2.16). CONCLUSION In patients referred to cardiac CT due to chest pain, we found a trend of an association between RA and the combined primary outcome, supporting that RA per se, but in particular seropositive and active RA, may increase the risk of CAD even after initial CAD diagnosis and treatment.
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Affiliation(s)
- Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital Skejby, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Ina Trolle Andersen
- Department of Clinical Epidemiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Anders Hammerich Riis
- Department of Clinical Epidemiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Hans Erik Bøtker
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus N, Denmark
| | | | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital Skejby, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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36
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Comparison of quantitative flow ratio and fractional flow reserve with myocardial perfusion scintigraphy and cardiovascular magnetic resonance as reference standard. A Dan-NICAD substudy. Int J Cardiovasc Imaging 2019; 36:395-402. [PMID: 31745744 PMCID: PMC7080669 DOI: 10.1007/s10554-019-01737-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/15/2019] [Indexed: 12/21/2022]
Abstract
Quantitative flow ratio (QFR) and fractional flow reserve (FFR) have not yet been compared head to head with perfusion imaging as reference for myocardial ischemia. We aimed to compare the diagnostic accuracy of QFR and FFR with myocardial perfusion scintigraphy (MPS) or cardiovascular magnetic resonance (CMR) as reference. This study is a predefined post hoc analysis of the Dan-NICAD study (NCT02264717). Patients with suspected coronary artery disease by coronary computed tomography angiography (CCTA) were randomized 1:1 to MPS or CMR and were referred to invasive coronary angiography with FFR and predefined QFR assessment. Paired data with FFR, QFR and MPS or CMR were available for 232 vessels with stenosis in 176 patients. Perfusion defects were detected in 57 vessel territories (25%). For QFR and FFR the diagnostic accuracy was 61% and 57% (p = 0.18) and area under the receiver operating curve was 0.64 vs. 0.58 (p = 0.22). Stenoses with absolute indication for stenting due to diameter stenosis > 90% by visual estimate were not classified as significant by either QFR or MPS/CMR in 21% (7 of 34) of cases. The diagnostic performance of QFR and FFR was similar but modest with MPS or CMR as reference. Comparable performance levels for QFR and FFR are encouraging for this pressure wire-free diagnostic method.
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Rasmussen LD, Winther S, Westra J, Isaksen C, Ejlersen JA, Brix L, Kirk J, Urbonaviciene G, Søndergaard HM, Hammid O, Schmidt SE, Knudsen LL, Madsen LH, Frost L, Petersen SE, Gormsen LC, Christiansen EH, Eftekhari A, Holm NR, Nyegaard M, Chiribiri A, Bøtker HE, Böttcher M. Danish study of Non-Invasive testing in Coronary Artery Disease 2 (Dan-NICAD 2): Study design for a controlled study of diagnostic accuracy. Am Heart J 2019; 215:114-128. [PMID: 31323454 DOI: 10.1016/j.ahj.2019.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronary computed tomography angiography (CTA) is the preferred primary diagnostic modality when examining patients with low to intermediate pre-test probability of coronary artery disease (CAD). Only 20-30% of these have potentially obstructive CAD. Because of the relatively poor positive predictive value of coronary CTA, unnecessary invasive coronary angiographies (ICAs) are conducted with the costs and risks associated with the procedure. Hence, an optimized diagnostic CAD algorithm may reduce the numbers of ICAs not followed by revascularization. The Dan-NICAD 2 study has 3 equivalent main aims: (1) To examine the diagnostic precision of a sound-based diagnostic algorithm, The CADScor®System (Acarix A/S, Denmark), in patients with a low to intermediate pre-test risk of CAD referred to a primary examination by coronary CTA. We hypothesize that the CADScor®System provides better stratification prior to coronary CTA than clinical risk stratification scores alone. (2) To compare the diagnostic accuracy of 3T cardiac magnetic resonance imaging (3T CMRI), 82rubidium positron emission tomography (82Rb-PET), and CT-derived fractional flow reserve (FFRCT) in patients where obstructive CAD cannot be ruled out by coronary CTA using ICA fractional flow reserve (FFR) as reference standard. (3) To compare the diagnostic performance of quantitative flow ratio (QFR) and ICA-FFR in patients with low to intermediate pre-test probability of CAD using 82Rb-PET as reference standard. METHODS Dan-NICAD 2 is a prospective, multicenter, cross-sectional study including approximately 2,000 patients with low to intermediate pre-test probability of CAD and without previous history of CAD. Patients are referred to coronary CTA because of symptoms suggestive of CAD, as evaluated by a cardiologist. Patient interviews, sound recordings, and blood samples are obtained in connection with the coronary CTA. If coronary CTA does not rule out obstructive CAD, patients will be examined by 3T CMRI 82Rb-PET, FFRCT, ICA, and FFR. Reference standard is ICA-FFR. Obstructive CAD is defined as an FFR ≤0.80 or as high-grade stenosis (>90% diameter stenosis) by visual assessment. Diagnostic performance will be evaluated as sensitivity, specificity, predictive values, likelihood ratios, calibration, and discrimination. Enrolment started January 2018 and is expected to be completed by June 2020. Patients are followed for 10 years after inclusion. DISCUSSION The results of the Dan-NICAD 2 study are expected to contribute to the improvement of diagnostic strategies for patients suspected of CAD in 3 different steps: risk stratification prior to coronary CTA, diagnostic strategy after coronary CTA, and invasive wireless QFR analysis as an alternative to ICA-FFR.
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Rønnow Sand NP, Nissen L, Winther S, Petersen SE, Westra J, Christiansen EH, Larsen P, Holm NR, Isaksen C, Urbonaviciene G, Deibjerg L, Husain M, Thomsen KK, Rohold A, Bøtker HE, Bøttcher M. Prediction of Coronary Revascularization in Stable Angina: Comparison of FFR CT With CMR Stress Perfusion Imaging. JACC Cardiovasc Imaging 2019; 13:994-1004. [PMID: 31422146 DOI: 10.1016/j.jcmg.2019.06.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/20/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study was designed to compare head-to-head fractional flow reserve (FFR) derived from coronary computed tomography angiography (CTA) (FFRCT) and cardiac magnetic resonance (CMR) stress perfusion imaging for prediction of standard-of-care-guided coronary revascularization in patients with stable chest pain and obstructive coronary artery disease by coronary CTA. BACKGROUND FFRCT is a novel modality for noninvasive functional testing. The clinical utility of FFRCT compared to CMR stress perfusion imaging in symptomatic patients with coronary artery disease is unknown. METHODS Prospective study of patients (n = 110) with stable angina pectoris and 1 or more coronary stenosis ≥50% by coronary CTA. All patients underwent invasive coronary angiography. Revascularization was FFR-guided in stenoses ranging from 30% to 90%. FFRCT ≤0.80 in 1 or more coronary artery or a reversible perfusion defect (≥2 segments) by CMR categorized patients with ischemia. FFRCT and CMR were analyzed by core laboratories blinded for patient management. RESULTS A total of 38 patients (35%) underwent revascularization. Per-patient diagnostic performance for identifying standard-of-care-guided revascularization, (95% confidence interval) yielded a sensitivity of 97% (86% to 100%) for FFRCT versus 47% (31% to 64%) for CMR, p < 0.001; corresponding specificity was 42% (30% to 54%) versus 88% (78% to 94%), p < 0.001; negative predictive value of 97% (91% to 100%) versus 76% (67% to 85%), p < 0.05; positive predictive value of 47% (36% to 58%) versus 67% (49% to 84%), p < 0.05; and accuracy of 61% (51% to 70%) versus 74% (64% to 82%), p > 0.05, respectively. CONCLUSIONS In patients with stable chest pain referred to invasive coronary angiography based on coronary CTA, FFRCT and CMR yielded similar overall diagnostic accuracy. Sensitivity for prediction of revascularization was highest for FFRCT, whereas specificity was highest for CMR.
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Affiliation(s)
- Niels Peter Rønnow Sand
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Louise Nissen
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
| | - Simon Winther
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark; Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Steffen E Petersen
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | | | - Pia Larsen
- Department of Epidemiology and Biostatistics, University of Southern Denmark, Odense, Denmark
| | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Christin Isaksen
- Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | | | - Lone Deibjerg
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Majed Husain
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Kristian K Thomsen
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Allan Rohold
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Morten Bøttcher
- Department of Cardiology, Hospital Unit West Jutland, Herning, Denmark
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Edvardsen T, Haugaa KH, Petersen SE, Gimelli A, Donal E, Maurer G, Popescu BA, Cosyns B. The year 2018 in the European Heart Journal - Cardiovascular Imaging: Part I. Eur Heart J Cardiovasc Imaging 2019; 20:858-865. [PMID: 31211353 DOI: 10.1093/ehjci/jez133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/17/2019] [Indexed: 12/18/2022] Open
Abstract
The European Heart Journal - Cardiovascular Imaging has become one of the leading multimodality cardiovascular imaging journal, since it was launched in 2012. The impact factor is an impressive 8.366 and it is now established as one of the top 10 cardiovascular journals. The journal is the most important cardiovascular imaging journal in Europe. The most important studies from 2018 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.
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Affiliation(s)
- Thor Edvardsen
- Department of Cardiology, Centre of Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Nydalen, Sognsvannsveien 20, NO-0424Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Sognsvannsveien 20, Oslo, Norway
| | - Kristina H Haugaa
- Department of Cardiology, Centre of Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Nydalen, Sognsvannsveien 20, NO-0424Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Sognsvannsveien 20, Oslo, Norway
| | - Steffen E Petersen
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK.,William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
| | - Alessia Gimelli
- Fondazione Toscana/CNR G. Monasterio, Via Moruzzi 1, Pisa, Italy
| | - Erwan Donal
- Cardiology Department and CIC-IT1414, CHU Rennes, 6 Rue H Le Guillou, Rennes, France.,LTSI INSERM 1099, University Rennes-1, Rue H Le Guillou, Rennes, France
| | - Gerald Maurer
- Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, Wien, Austria
| | - Bogdan A Popescu
- University of Medicine and Pharmacy "Carol Davila"-Euroecolab, Department of Cardiology, Emergency Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos. Fundeni 258, Sector 2, Bucharest, Romania
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair Ziekenhuis Brussel, 109 Laarbeeklaan, Brussels, Belgium
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Comparison of diagnostic accuracy of stress myocardial perfusion imaging for detecting hemodynamically significant coronary artery disease between cardiac magnetic resonance and nuclear medical imaging: A meta-analysis. Int J Cardiol 2019; 293:278-285. [PMID: 31303392 DOI: 10.1016/j.ijcard.2019.06.054] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/03/2019] [Accepted: 06/18/2019] [Indexed: 11/22/2022]
Abstract
AIMS This study aimed to compare the diagnostic accuracy of stress myocardial perfusion imaging between cardiac magnetic resonance (CMR) and nuclear medical imaging, including single-photon emission computed tomography (SPECT) and positron emission tomography (PET), for the diagnosis of hemodynamically significant coronary artery disease (CAD) with fractional flow reserve (FFR) as the reference standard. METHODS AND RESULTS We searched PubMed and Embase for all published studies that evaluated the diagnostic accuracy of stress myocardial perfusion imaging modalities, including CMR, SPECT, and PET, to diagnose hemodynamically significant CAD with FFR as the reference standard. A total of 28 articles met the inclusion criteria and were included in the meta-analysis: 14 CMR, 13 SPECT, and 5 PET articles. The results demonstrated a pooled sensitivity of 0.88 (95% confidence interval [CI]: 0.80-0.93), 0.69 (95% CI: 0.56-0.79), and 0.83 (95% CI: 0.70-0.91), and a pooled specificity of 0.89 (95% CI: 0.85-0.93), 0.85 (95% CI, 0.80-0.89), and 0.89 (95% CI, 0.86-0.91) for CMR, SPECT, and PET, respectively. The area under the curve (AUC) of CMR, PET, and SPECT was 0.94 (95% CI, 0.92-0.96), 0.92 (95% CI, 0.89-0.94), and 0.87 (95% CI, 0.83-0.89), respectively. CONCLUSIONS CMR and PET both have high accuracy and SPECT has moderate accuracy to detect hemodynamically significant CAD with FFR as the reference standard. Furthermore, the diagnostic accuracy of CMR at 3.0 T is superior to 1.5 T.
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Ko BS, Linde JJ, Ihdayhid AR, Norgaard BL, Kofoed KF, Sørgaard M, Adams D, Crossett M, Cameron JD, Seneviratne SK. Non-invasive CT-derived fractional flow reserve and static rest and stress CT myocardial perfusion imaging for detection of haemodynamically significant coronary stenosis. Int J Cardiovasc Imaging 2019; 35:2103-2112. [PMID: 31273632 PMCID: PMC6805817 DOI: 10.1007/s10554-019-01658-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/24/2019] [Indexed: 12/25/2022]
Abstract
Computed tomography derived fractional flow reserve (FFRCT) and computed tomography stress myocardial perfusion imaging (CTP) are techniques to assess haemodynamic significance of coronary stenosis. To compare the diagnostic performance of FFRCT and static rest/stress CTP in detecting fractional flow reserve (FFR) defined haemodynamically-significant stenosis (FFR ≤ 0.8). Fifty-one patients (96 vessels) with suspected coronary artery disease from a single institution planned for elective invasive-angiography prospectively underwent research indicated 320-detector-CT-coronary-angiography (CTA) and adenosine-stress CTP and invasive FFR. Analyses were performed in separate core-laboratories for FFRCT and CTP blinded to FFR results. Myocardial perfusion was assessed visually and semi-quantitatively by transmural perfusion ratio (TPR). Invasive FFR ≤ 0.8 was present in 33% of vessels and 49% of patients. FFRCT, visual CTP and TPR analysis was feasible in 96%, 92% and 92% of patients respectively. Overall per-vessel sensitivity, specificity and diagnostic accuracy for FFRCT were 81%, 85%, 84%, for visual CTP were 50%, 89%, 75% and for TPR were 69%, 48%, 56% respectively. Receiver-operating-characteristics curve analysis demonstrated larger per vessel area-under-curve (AUC) for FFRCT (0.89) compared with visual CTP (0.70; p < 0.001), TPR (0.58; p < 0.001) and CTA (0.70; p = 0.0007); AUC for CTA + FFRCT (0.91) was higher than CTA + visual CTP (0.77, p = 0.008) and CTA + TPR (0.74, p < 0.001). Per-patient AUC for FFRCT (0.90) was higher than visual CTP (0.69; p = 0.0016), TPR (0.56; p < 0.0001) and CTA (0.68; p = 0.001). Based on this selected cohort of patients FFRCT is superior to visually and semi-quantitatively assessed static rest/stress CTP in detecting haemodynamically-significant coronary stenosis as determined on invasive FFR.
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Affiliation(s)
- Brian S Ko
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, VIC, Australia.
| | - Jesper J Linde
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Abdul-Rahman Ihdayhid
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, VIC, Australia
| | - Bjarne L Norgaard
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Sørgaard
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Adams
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, VIC, Australia
| | - Marcus Crossett
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, VIC, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, VIC, Australia
| | - Sujith K Seneviratne
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health, Clayton, VIC, Australia
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Shiono Y, Matsuo H, Kawasaki T, Amano T, Kitabata H, Kubo T, Morino Y, Yoda S, Sakamoto T, Ito H, Shite J, Otake H, Tanaka N, Terashima M, Kadota K, Patel MR, Nieman K, Rogers C, Nørgaard BL, Bax JJ, Raff GL, Chinnaiyan KM, Berman DS, Fairbairn TA, Hurwitz Koweek LM, Leipsic J, Akasaka T. Clinical Impact of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve on Japanese Population in the ADVANCE Registry. Circ J 2019; 83:1293-1301. [DOI: 10.1253/circj.cj-18-1269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Value of Relative Myocardial Perfusion at MRI for Fractional Flow Reserve-Defined Ischemia: A Pilot Study. AJR Am J Roentgenol 2019; 212:1002-1009. [PMID: 30860888 DOI: 10.2214/ajr.18.20469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE. Correcting the perfusion in areas distal to coronary stenosis (risk) according to that of normal (remote) areas defines the relative myocardial perfusion index, which is similar to the fractional flow reserve (FFR) concept. The aim of this study was to assess the value of relative myocardial perfusion by MRI in predicting lesion-specific inducible ischemia as defined by FFR. MATERIALS AND METHODS. Forty-six patients (33 men and 13 women; mean [± SD] age, 61 ± 9 years) who underwent adenosine perfusion MRI and FFR measurement distal to 49 coronary artery stenoses during coronary angiography were retrospectively evaluated. Subendocardial time-enhancement maximal upslopes, normalized by the respective left ventricle cavity upslopes, were obtained in risk and remote subendocardium during adenosine and rest MRI perfusion and were correlated to the FFR values. RESULTS. The mean FFR value was 0.84 ± 0.09 (range, 0.60-0.98) and was less than or equal to 0.80 in 31% of stenoses (n = 15). The relative subendocardial perfusion index (risk-to-remote upslopes) during hyperemia showed better correlations with the FFR value (r = 0.59) than the uncorrected risk perfusion parameters (i.e., both the upslope during hyperemia and the perfusion reserve index [stress-to-rest upslopes]; r = 0.27 and 0.29, respectively). A cutoff value of 0.84 of the relative subendocardial perfusion index had an ROC AUC of 0.88 to predict stenosis at an FFR of less than or equal to 0.80. CONCLUSION. Using adenosine perfusion MRI, the relative myocardial perfusion index enabled the best prediction of FFR-defined lesion-specific myocardial ischemia. This index could be used to noninvasively determine the need for revascularization of known coronary stenoses.
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Nissen L, Winther S, Westra J, Ejlersen JA, Isaksen C, Rossi A, Holm NR, Urbonaviciene G, Gormsen LC, Madsen LH, Christiansen EH, Maeng M, Knudsen LL, Frost L, Brix L, Bøtker HE, Petersen SE, Bøttcher M. Influence of Cardiac CT based disease severity and clinical symptoms on the diagnostic performance of myocardial perfusion. Int J Cardiovasc Imaging 2019; 35:1709-1720. [PMID: 31016502 DOI: 10.1007/s10554-019-01604-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/15/2019] [Indexed: 12/14/2022]
Abstract
We aimed to identify factors influencing the sensitivity of perfusion imaging after an initial positive coronary computed tomography angiography (CCTA) using invasive coronary angiography (ICA) with conditional fractional flow reserve (FFR) as reference. Secondly we aimed to identify factors associated with revascularisation and to evaluate treatment outcome after ICA. We analysed 292 consecutive patients with suspected significant coronary artery disease (CAD) at CCTA, who underwent perfusion imaging with either cardiac magnetic resonance (CMR) or myocardial perfusion scintigraphy (MPS) followed by ICA with conditional FFR. Stratified analysis and uni- and multiple logistic regression analyses were performed to identify predictors of diagnostic agreement between perfusion scans and ICA and predictors of revascularisation. Myocardial ischemia evaluated with perfusion scans was present in 65/292 (22%) while 117/292 (40%) had obstructive CAD evaluated by ICA. Revascularisation rate was 90/292 (31%). The overall sensitivity for perfusion scans was 39% (30-48), specificity 89% (83-93), PPV 69% (57-80) and NPV 68% (62-74). Stratified analysis showed higher sensitivities in patients with multi-vessel disease at CCTA 49% (37-60) and typical chest pain 50% (37-60). Predictors of revascularisation were multi-vessel disease by CCTA (OR 3.51 [1.91-6.48]) and a positive perfusion scan (OR 4.69 [2.49-8.83]). The sensitivity for perfusion scans after CCTA was highest in patients with typical angina and multiple lesions at CCTA and predicted diagnostic agreement between perfusion scans and ICA. Abnormal perfusion and multi vessel disease at CCTA predicted revascularisation.
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Affiliation(s)
- L Nissen
- Department of Cardiology, Hospital Unit West Jutland, Gl. Landevej 61, Herning, 7400, Denmark.
| | - S Winther
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - J Westra
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - J A Ejlersen
- Department of Nuclear Medicine, Hospital Unit West Jutland, Herning, Denmark
| | - C Isaksen
- Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - A Rossi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Diagnostic Imaging, Humanitas Research Hospital, Milan, Italy
| | - N R Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - G Urbonaviciene
- Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - L C Gormsen
- Department of Nuclear Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - L H Madsen
- Department of Cardiology, Hospital Unit West Jutland, Gl. Landevej 61, Herning, 7400, Denmark
| | - E H Christiansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - M Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - L L Knudsen
- Department of Cardiology, Hospital Unit West Jutland, Gl. Landevej 61, Herning, 7400, Denmark
| | - L Frost
- Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - L Brix
- Department of Radiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | - H E Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - S E Petersen
- William Harvey Research Institute, Queen Mary University of London, London, UK
- St. Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - M Bøttcher
- Department of Cardiology, Hospital Unit West Jutland, Gl. Landevej 61, Herning, 7400, Denmark
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Dynamic Stress Computed Tomography Perfusion With a Whole-Heart Coverage Scanner in Addition to Coronary Computed Tomography Angiography and Fractional Flow Reserve Computed Tomography Derived. JACC Cardiovasc Imaging 2019; 12:2460-2471. [PMID: 31005531 DOI: 10.1016/j.jcmg.2019.02.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/22/2019] [Accepted: 02/01/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aims of the study were to test the diagnostic accuracy of integrated evaluation of dynamic myocardial computed tomography perfusion (CTP) on top of coronary computed tomography angiography (cCTA) plus fractional flow reserve computed tomography derived (FFRCT) by using a whole-heart coverage computed tomography (CT) scanner as compared with clinically indicated invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR). BACKGROUND Recently, new techniques such as dynamic stress computed tomography perfusion (stress-CTP) emerged as potential strategies to combine anatomical and functional evaluation in a one-shot scan. However, previous experiences with this technique were associated with high radiation exposure. METHODS Eighty-five consecutive symptomatic patients scheduled for ICA were prospectively enrolled. All patients underwent rest cCTA followed by stress dynamic CTP with a whole-heart coverage CT scanner (Revolution CT, GE Healthcare, Milwaukee, Wisconsin). FFRCT was also measured by using the rest cCTA dataset. The diagnostic accuracy to detect functionally significant coronary artery disease (CAD) in a vessel-based model of cCTA alone, cCTA+FFRCT, cCTA+CTP, or cCTA+FFRCT+CTP were assessed and compared by using ICA and invasive FFR as reference. The overall effective dose of dynamic CTP was also measured. RESULTS The prevalence of obstructive CAD and functionally significant CAD was 77% and 57%, respectively. The sensitivity and specificity of cCTA alone, cCTA+FFRCT, and cCTA+CTP were 83% and 66%, 86% and 75%, and 73% and 86%, respectively. Both the addition of FFRCT and CTP improves the area under the curve (AUC: 0.876 and 0.878, respectively) as compared with cCTA alone (0.826; p < 0.05). The sequential strategy of cCTA+FFRCT+CTP showed the highest AUC (0.919; p < 0.05) as compared with all other strategies. The mean effective radiation dose (ED) for cCTA and stress CTP was 2.8 ± 1.2 mSv and 5.3 ± 0.7 mSv, respectively. CONCLUSIONS The addition of dynamic stress CTP on top of cCTA and FFRCT provides additional diagnostic accuracy with acceptable radiation exposure.
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Winther S, Nissen L, Westra J, Schmidt SE, Bouteldja N, Knudsen LL, Madsen LH, Frost L, Urbonaviciene G, Holm NR, Christiansen EH, Bøtker HE, Bøttcher M. Pre-test probability prediction in patients with a low to intermediate probability of coronary artery disease: a prospective study with a fractional flow reserve endpoint. Eur Heart J Cardiovasc Imaging 2019; 20:1208-1218. [PMID: 31083725 DOI: 10.1093/ehjci/jez058] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/28/2018] [Accepted: 03/11/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Aims
European and North American guidelines currently recommend pre-test probability (PTP) stratification based on simple probability models in patients with suspected coronary artery disease (CAD). However, no unequivocal recommendation has yet been established. We aimed to compare the ability of risk factors and different PTP stratification models to predict haemodynamically obstructive CAD with fractional flow reserve (FFR) as reference in low to intermediate probability patients.
Methods and results
We prospectively included 1675 patients with low to intermediate risk who had been referred to coronary computed tomography angiography (CTA). Patients with coronary stenosis were subsequently investigated by invasive coronary angiography (ICA) with FFR measurement if indicated. Discrimination and calibration were assessed for four models: the updated Diamond–Forrester (UDF), the CAD Consortium Basic, the Clinical, and the Clinical + Coronary artery calcium score (CACS). At coronary CTA, 24% of patients were diagnosed with a suspected stenosis and 10% had haemodynamically obstructive CAD at the ICA. Calibration for all CAD Consortium models increased compared with the UDF score. However, all models overestimated the probability of haemodynamically obstructive CAD. Discrimination increased by area under the receiver operating curve from 67% to 86% for UDF vs. CAD Consortium Clinical + CACS. The proportion of low-probability patients (pre-test score < 15%) was for the UDF, CAD Consortium Basic, Clinical, and Clinical + CACS: 14%, 58%, 51%, and 66%, respectively. The corresponding negative predictive values were 97%, 94%, 95%, and 98%, respectively.
Conclusion
CAD Consortium models improve PTP stratification compared with the UDF score, mainly due to superior calibration in low to intermediate probability patients. Adding the coronary calcium score to the models substantially increases discrimination.
Clinical Trials. gov identifier
NCT02264717.
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Affiliation(s)
- Simon Winther
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK Aarhus, Denmark
- Department of Cardiology, Hospital Unit West, Herning, Denmark
| | - Louise Nissen
- Department of Cardiology, Hospital Unit West, Herning, Denmark
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK Aarhus, Denmark
| | - Samuel Emil Schmidt
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Nadia Bouteldja
- Department of Cardiology, Hospital Unit West, Herning, Denmark
| | | | | | - Lars Frost
- Department of Cardiology, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | | | - Niels Ramsing Holm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK Aarhus, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK Aarhus, Denmark
| | - Morten Bøttcher
- Department of Cardiology, Hospital Unit West, Herning, Denmark
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Sand NPR, Veien KT, Nielsen SS, Nørgaard BL, Larsen P, Johansen A, Hess S, Deibjerg L, Husain M, Junker A, Thomsen KK, Rohold A, Jensen LO. Prospective Comparison of FFR Derived From Coronary CT Angiography With SPECT Perfusion Imaging in Stable Coronary Artery Disease: The ReASSESS Study. JACC Cardiovasc Imaging 2018; 11:1640-1650. [PMID: 29909103 DOI: 10.1016/j.jcmg.2018.05.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study sought to compare the per-patient diagnostic performance of coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT) with that of single-photon emission computed tomography (SPECT), using a fractional flow reserve (FFR) value of ≤0.80 as the reference for diagnosing at least 1 hemodynamically significant stenosis in a head-to-head comparison of patients with intermediate coronary stenosis as determined by coronary CTA. BACKGROUND No previous study has prospectively compared the diagnostic performance of FFRCT and myocardial perfusion imaging by SPECT in symptomatic patients with intermediate range coronary artery disease (CAD). METHODS This study was conducted at a single-center as a prospective study in patients with stable angina pectoris (N = 143). FFRCT and SPECT analyses were performed by core laboratories and were blinded for the personnel responsible for downstream patient management. FFRCT ≤0.80 distally in at least 1 coronary artery with a diameter ≥2 mm classified patients as having ischemia. Ischemia by SPECT was encountered if a reversible perfusion defect (summed difference score ≥2) or transitory ischemic dilation of the left ventricle (ratio >1.19) were found. RESULTS The per-patient diagnostic performance for identifying ischemia (95% confidence interval [CI]), FFRCT versus SPECT, were sensitivity of 91% (95% CI: 81% to 97%) versus 41% (95% CI: 29% to 55%; p < 0.001); specificity of 55% (95% CI: 44% to 66%) versus 86% (95% CI: 77% to 93%; p < 0.001); negative predictive value of 90% (95% CI: 82% to 98%) versus 68% (95% CI: 59% to 77%; p = 0.001); positive predictive value of 58% (95% CI: 48% to 68%) versus 67% (95% CI: 51% to 82%; p = NS); and accuracy of 70% (95% CI: 62% to 77%) versus 68% (95% CI: 60% to 75%; p = NS) respectively. CONCLUSIONS In patients with stable chest pain and CAD as determined by coronary CTA, the overall diagnostic accuracy levels of FFRCT and SPECT were identical in assessing hemodynamically significant stenosis. However, FFRCT demonstrated a significantly higher diagnostic sensitivity than SPECT.
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Affiliation(s)
- Niels Peter Rønnow Sand
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | | | - Søren Steen Nielsen
- Department of Nuclear Medicine, Aalborg University Hospital, Aalborg, Denmark
| | | | - Pia Larsen
- Department of Epidemiology, Biostatistics and Bioinformatics, University of Southern Denmark, Odense, Denmark
| | - Allan Johansen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Hess
- Department of Radiology and Nuclear Medicine, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Lone Deibjerg
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Majed Husain
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
| | - Anders Junker
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Allan Rohold
- Department of Cardiology, Hospital of Southwest Denmark, Esbjerg, Denmark
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Saraste A, Knuuti J. Evaluation of coronary artery disease after computed tomography angiography. Eur Heart J Cardiovasc Imaging 2018; 19:378-379. [DOI: 10.1093/ehjci/jey020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Antti Saraste
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, 20520 Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, 20520 Turku, Finland
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