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Chan K, Wahome E, Tsiachristas A, Antonopoulos AS, Patel P, Lyasheva M, Kingham L, West H, Oikonomou EK, Volpe L, Mavrogiannis MC, Nicol E, Mittal TK, Halborg T, Kotronias RA, Adlam D, Modi B, Rodrigues J, Screaton N, Kardos A, Greenwood JP, Sabharwal N, De Maria GL, Munir S, McAlindon E, Sohan Y, Tomlins P, Siddique M, Kelion A, Shirodaria C, Pugliese F, Petersen SE, Blankstein R, Desai M, Gersh BJ, Achenbach S, Libby P, Neubauer S, Channon KM, Deanfield J, Antoniades C. Inflammatory risk and cardiovascular events in patients without obstructive coronary artery disease: the ORFAN multicentre, longitudinal cohort study. Lancet 2024; 403:2606-2618. [PMID: 38823406 DOI: 10.1016/s0140-6736(24)00596-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/20/2024] [Accepted: 03/22/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) is the first line investigation for chest pain, and it is used to guide revascularisation. However, the widespread adoption of CCTA has revealed a large group of individuals without obstructive coronary artery disease (CAD), with unclear prognosis and management. Measurement of coronary inflammation from CCTA using the perivascular fat attenuation index (FAI) Score could enable cardiovascular risk prediction and guide the management of individuals without obstructive CAD. The Oxford Risk Factors And Non-invasive imaging (ORFAN) study aimed to evaluate the risk profile and event rates among patients undergoing CCTA as part of routine clinical care in the UK National Health Service (NHS); to test the hypothesis that coronary arterial inflammation drives cardiac mortality or major adverse cardiac events (MACE) in patients with or without CAD; and to externally validate the performance of the previously trained artificial intelligence (AI)-Risk prognostic algorithm and the related AI-Risk classification system in a UK population. METHODS This multicentre, longitudinal cohort study included 40 091 consecutive patients undergoing clinically indicated CCTA in eight UK hospitals, who were followed up for MACE (ie, myocardial infarction, new onset heart failure, or cardiac death) for a median of 2·7 years (IQR 1·4-5·3). The prognostic value of FAI Score in the presence and absence of obstructive CAD was evaluated in 3393 consecutive patients from the two hospitals with the longest follow-up (7·7 years [6·4-9·1]). An AI-enhanced cardiac risk prediction algorithm, which integrates FAI Score, coronary plaque metrics, and clinical risk factors, was then evaluated in this population. FINDINGS In the 2·7 year median follow-up period, patients without obstructive CAD (32 533 [81·1%] of 40 091) accounted for 2857 (66·3%) of the 4307 total MACE and 1118 (63·7%) of the 1754 total cardiac deaths in the whole of Cohort A. Increased FAI Score in all the three coronary arteries had an additive impact on the risk for cardiac mortality (hazard ratio [HR] 29·8 [95% CI 13·9-63·9], p<0·001) or MACE (12·6 [8·5-18·6], p<0·001) comparing three vessels with an FAI Score in the top versus bottom quartile for each artery. FAI Score in any coronary artery predicted cardiac mortality and MACE independently from cardiovascular risk factors and the presence or extent of CAD. The AI-Risk classification was positively associated with cardiac mortality (6·75 [5·17-8·82], p<0·001, for very high risk vs low or medium risk) and MACE (4·68 [3·93-5·57], p<0·001 for very high risk vs low or medium risk). Finally, the AI-Risk model was well calibrated against true events. INTERPRETATION The FAI Score captures inflammatory risk beyond the current clinical risk stratification and CCTA interpretation, particularly among patients without obstructive CAD. The AI-Risk integrates this information in a prognostic algorithm, which could be used as an alternative to traditional risk factor-based risk calculators. FUNDING British Heart Foundation, NHS-AI award, Innovate UK, National Institute for Health and Care Research, and the Oxford Biomedical Research Centre.
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Affiliation(s)
- Kenneth Chan
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Elizabeth Wahome
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Apostolos Tsiachristas
- Nuffield Department of Primary Care Health Sciences & Department of Psychiatry, University of Oxford, Oxford, UK
| | - Alexios S Antonopoulos
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Parijat Patel
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Maria Lyasheva
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lucy Kingham
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Henry West
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Evangelos K Oikonomou
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lucrezia Volpe
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Michail C Mavrogiannis
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Edward Nicol
- Royal Brompton and Harefield Hospitals, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
| | | | - Thomas Halborg
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Rafail A Kotronias
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Bhavik Modi
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | | | | | - Attila Kardos
- Milton Keynes University Hospital NHS Trust, Milton Keynes, UK
| | - John P Greenwood
- Leeds University and Leeds Teaching Hospitals NHS Trust, Leeds, UK; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Nikant Sabharwal
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Giovanni Luigi De Maria
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | | | | | | | | | | | - Andrew Kelion
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Cheerag Shirodaria
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; Caristo Diagnostics, Oxford, UK
| | - Francesca Pugliese
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK; William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK; William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Milind Desai
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Bernard J Gersh
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA; Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Peter Libby
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan Neubauer
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Keith M Channon
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - John Deanfield
- Institute of Cardiovascular Science, University College London, London, UK
| | - Charalambos Antoniades
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.
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Zhang X, Cao Z, Xu J, Guan X, He H, Duan L, Ji L, Liu G, Guo Q, You Y, Zheng M, Wei M. Peri-coronary fat attenuation index combined with high-risk plaque characteristics quantified from coronary computed tomography angiography for risk stratification in new-onset chest pain individuals without acute myocardial infarction. PLoS One 2024; 19:e0304137. [PMID: 38805487 PMCID: PMC11132441 DOI: 10.1371/journal.pone.0304137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/07/2024] [Indexed: 05/30/2024] Open
Abstract
This study aims to evaluate the role of the peri-coronary Fat Attenuation Index (FAI) and High-Risk Plaque Characteristics (HRPC) in the assessment of coronary heart disease risk. By conducting coronary CT angiography and coronary angiography on 217 patients with newly developed chest pain (excluding acute myocardial infarction), their degree of vascular stenosis, FAI, and the presence and quantity of HRPC were assessed. The study results demonstrate a correlation between FAI and HRPC, and the combined use of FAI and HRPC can more accurately predict the risk of major adverse cardiovascular events (MACE). Additionally, the study found that patients with high FAI were more prone to exhibit high-risk plaque characteristics, severe stenosis, and multiple vessel disease. After adjustment, the combination of FAI and HRPC improved the ability to identify and reclassify MACE. Furthermore, the study identified high FAI as an independent predictor of MACE in patients undergoing revascularization, while HRPC served as an independent predictor of MACE in patients not undergoing revascularization. These findings suggest the potential clinical value of FAI and HRPC in the assessment of coronary heart disease risk, particularly in patients with newly developed chest pain excluding acute myocardial infarction.
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Affiliation(s)
- Xuelong Zhang
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zelong Cao
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jianan Xu
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xing Guan
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Honghou He
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Linan Duan
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lishuang Ji
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Gang Liu
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Qifeng Guo
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yang You
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Mingqi Zheng
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Hebei Key Laboratory of Heart and Metabolism, Shijiazhuang, Hebei, China
| | - Mei Wei
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Hofmann BM, Brandsaeter IØ, Andersen ER, Porthun J, Kjelle E. Temporal and geographical variations in diagnostic imaging in Norway. BMC Health Serv Res 2024; 24:463. [PMID: 38610021 PMCID: PMC11015609 DOI: 10.1186/s12913-024-10869-5] [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: 09/25/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services. OBJECTIVE To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021. METHODS Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics. RESULTS More than 37 million examinations were performed in Norway during 2013-2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust. CONCLUSION As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values.
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Affiliation(s)
- Bjørn Morten Hofmann
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway.
- Centre for Medical Ethics, University of Oslo, PO Box 1130, 0318, Blindern, Oslo, Norway.
| | - Ingrid Øfsti Brandsaeter
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
| | - Jan Porthun
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
| | - Elin Kjelle
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
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Morris MF, Chandrasekhar M, Gudi H, Schumann C, Benson B, Ng N, Mullen S, Huey W, O'Neal W. A Study to Measure the Ability of AI-CSQ to suppoRt The busy CCTA reader: SMART-CT. J Cardiovasc Comput Tomogr 2024; 18:213-214. [PMID: 37821353 DOI: 10.1016/j.jcct.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Affiliation(s)
| | | | - Harish Gudi
- Banner University Medical Center-Tucson, Tucson, AZ, USA
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Catapano F, Moser LJ, Francone M, Catalano C, Vliegenthart R, Budde RPJ, Salgado R, Hrabak Paar M, Pirnat M, Loewe C, Nikolaou K, Williams MC, Muscogiuri G, Natale L, Lehmkuhl L, Sieren MM, Gutberlet M, Alkadhi H. Competence of radiologists in cardiac CT and MR imaging in Europe: insights from the ESCR Registry. Eur Radiol 2024:10.1007/s00330-024-10644-4. [PMID: 38418626 DOI: 10.1007/s00330-024-10644-4] [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: 12/28/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
RATIONALE To provide an overview of the current status of cardiac multimodality imaging practices in Europe and radiologist involvement using data from the European Society of Cardiovascular Radiology (ESCR) MRCT-registry. MATERIALS AND METHODS Numbers on cardiac CT and MRI examinations were extracted from the MRCT-registry of the ESCR, entered between January 2011 and October 2023 (n = 432,265). Data collection included the total/annual numbers of examinations, indications, complications, and reporting habits. RESULTS Thirty-two countries contributed to the MRCT-registry, including 29 European countries. Between 2011 and 2022, there was a 4.5-fold increase in annually submitted CT examinations, from 3368 to 15,267, and a 3.8-fold increase in MRI examinations, from 3445 to 13,183. The main indications for cardiac CT were suspected coronary artery disease (CAD) (59%) and transcatheter aortic valve replacement planning (21%). The number of patients with intermediate pretest probability who underwent CT for suspected CAD showed an increase from 61% in 2012 to 82% in 2022. The main MRI indications were suspected myocarditis (26%), CAD (21%), and suspected cardiomyopathy (19%). Adverse event rates were very low for CT (0.3%) and MRI (0.7%) examinations. Reporting of CT and MRI examinations was performed mainly by radiologists (respectively 76% and 71%) and, to a lesser degree, in consensus with non-radiologists (19% and 27%, respectively). The remaining examinations (4.9% CT and 1.7% MRI) were reported by non-radiological specialties or in separate readings of radiologists and non-radiologists. CONCLUSIONS Real-life data on cardiac imaging in Europe using the largest available MRCT-registry demonstrate a considerable increase in examinations over the past years, the vast majority of which are read by radiologists. These findings indicate that radiologists contribute to meeting the increasing demands of competent and effective care in cardiac imaging to a relevant extent. CLINICAL RELEVANCE STATEMENT The number of cardiac CT and MRI examinations has risen over the past years, and radiologists read the vast majority of these studies as recorded in the MRCT-registry. KEY POINTS • The number of cardiac imaging examinations is constantly increasing. • Radiologists play a central role in providing cardiac CT and MR imaging services to a large volume of patients. • Cardiac CT and MR imaging examinations performed and read by radiologists show a good safety profile.
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Affiliation(s)
- Federica Catapano
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Lukas Jakob Moser
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Marco Francone
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Rozemarijn Vliegenthart
- Department of Radiology, University of Groningen/University Medical Center Groningen, Groningen, The Netherlands
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rodrigo Salgado
- Department of Radiology, Antwerp University Hospital & Antwerp University, Holy Heart Lier, Lier, Belgium
| | - Maja Hrabak Paar
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Maja Pirnat
- Radiology Department, University Medical Centre Maribor, Maribor, Slovenia
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Tübingen, Germany
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Giuseppe Muscogiuri
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Luigi Natale
- Department of Radiological Sciences - Institute of Radiology, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Lukas Lehmkuhl
- Clinic for Radiology, Heart Center Bad Neustadt a.d. Saale, Bad Neustadt a.d. Saale, Germany
| | - Malte Maria Sieren
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Ratzeburger Lübeck, Germany
- Institute of Interventional Radiology, University Hospital Schleswig-Holstein, Ratzeburger Lübeck, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
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Wang J, Xu J, Mao J, Fu S, Gu H, Wu N, Su G, Lin Z, Zhang K, Lin Y, Zhao Y, Liu G, Zhao H, Zhao Q. A novel hybrid machine learning model for auxiliary diagnosing myocardial ischemia. Front Cardiovasc Med 2024; 11:1327912. [PMID: 38450372 PMCID: PMC10914931 DOI: 10.3389/fcvm.2024.1327912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/22/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Accurate identification of the myocardial texture features of fat around the coronary artery on coronary computed tomography angiography (CCTA) images are crucial to improve clinical diagnostic efficiency of myocardial ischemia (MI). However, current coronary CT examination is difficult to recognize and segment the MI characteristics accurately during earlier period of inflammation. Materials and methods We proposed a random forest model to automatically segment myocardium and extract peripheral fat features. This hybrid machine learning (HML) model is integrated by CCTA images and clinical data. A total of 1,316 radiomics features were extracted from CCTA images. To further obtain the features that contribute the most to the diagnostic model, dimensionality reduction was applied to filter features to three: LNS, GFE, and WLGM. Moreover, statistical hypothesis tests were applied to improve the ability of discriminating and screening clinical features between the ischemic and non-ischemic groups. Results By comparing the accuracy, recall, specificity and AUC of the three models, it can be found that HML had the best performance, with the value of 0.848, 0.762, 0.704 and 0.729. Conclusion In sum, this study demonstrates that ML-based radiomics model showed good predictive value in MI, and offer an enhanced tool for predicting prognosis with greater accuracy.
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Affiliation(s)
- Jing Wang
- Department of Imaging, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Jing Xu
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Innovation Platform for Industry-Education Integration in Vaccine Research, Xiamen University, Xiamen, China
| | - Jingsong Mao
- Department of Vascular Intervention, Affiliated Hospital, Guilin Medical University, Guilin, China
| | - Suzhong Fu
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Innovation Platform for Industry-Education Integration in Vaccine Research, Xiamen University, Xiamen, China
| | - Haowei Gu
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Innovation Platform for Industry-Education Integration in Vaccine Research, Xiamen University, Xiamen, China
| | - Naiming Wu
- Department of Imaging, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Guoqing Su
- Department of Radiology, Xiang’an Hospital of Xiamen University, Xiamen, China
| | - Zhiping Lin
- Department of Pharmaceutical Diagnosis, GE Healthcare, Guangzhou, China
| | - Kaiyue Zhang
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
| | - Yuetong Lin
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
| | - Yang Zhao
- Department of Mechanical and Electrical Engineering, Xiamen University, Xiamen, China
| | - Gang Liu
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
| | - Hengyu Zhao
- Department of Imaging, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Qingliang Zhao
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, Institute of Artificial Intelligence, School of Public Health, Innovation Laboratory for Sciences and Technologies of Energy Materials of Fujian Province (IKKEM), Xiamen University, Xiamen, China
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Innovation Platform for Industry-Education Integration in Vaccine Research, Xiamen University, Xiamen, China
- Shenzhen Research Institute of Xiamen University, Shenzhen, China
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Lee DY, Chang CC, Ko CF, Lee YH, Tsai YL, Chou RH, Chang TY, Guo SM, Huang PH. Artificial intelligence evaluation of coronary computed tomography angiography for coronary stenosis classification and diagnosis. Eur J Clin Invest 2024; 54:e14089. [PMID: 37668089 DOI: 10.1111/eci.14089] [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: 07/09/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Ruling out obstructive coronary artery disease (CAD) using coronary computed tomography angiography (CCTA) is time-consuming and challenging. This study developed a deep learning (DL) model to assist in detecting obstructive CAD on CCTA to streamline workflows. METHODS In total, 2929 DICOM files and 7945 labels were extracted from curved planar reformatted CCTA images. A modified Inception V3 model was adopted. To validate the artificial intelligence (AI) model, two cardiologists labelled and adjudicated the classification of coronary stenosis on CCTA. The model was trained to differentiate the coronary artery into binary stenosis classifications <50% and ≥50% stenosis. Using the quantitative coronary angiography (QCA) consensus results as a reference standard, the performance of the AI model and CCTA radiology readers was compared by calculating Cohen's kappa coefficients at patient and vessel levels. The net reclassification index was used to evaluate the net benefit of the DL model. RESULTS The diagnostic accuracy of the AI model was 92.3% and 88.4% at the patient and vessel levels, respectively. Compared with CCTA radiology readers, the AI model had a better agreement for binary stenosis classification at both patient and vessel levels (Cohen kappa coefficient: .79 vs. .39 and .77 vs. .40, p < .0001). The AI model also exhibited significantly improved model discrimination and reclassification (Net reclassification index = .350; Z = 4.194; p < .001). CONCLUSIONS The developed AI model identified obstructive CAD, and the model results correlated well with QCA results. Incorporating the model into the reporting system of CCTA may improve workflows.
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Affiliation(s)
- Dan-Ying Lee
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Chun-Chin Chang
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Chieh-Fu Ko
- Institute of Medical Informatics, National Cheng Kung University, Tainan City, Taiwan
| | - Yin-Hao Lee
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Medicine, Division of Cardiology, Taipei City Hospital, Taipei City, Taiwan
| | - Yi-Lin Tsai
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Ruey-Hsing Chou
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Ting-Yung Chang
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Shu-Mei Guo
- Institute of Medical Informatics, National Cheng Kung University, Tainan City, Taiwan
| | - Po-Hsun Huang
- Department of Internal Medicine, Division of Cardiology, Taipei Veterans General Hospital, Taipei City, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan
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8
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Murphy D, Stephenson J, Bouhbib Y, Graby J, Khavandi A, Lyen S, Hudson B, Rodrigues JCL. Investigating the impact of non-gated thoracic CT prior to CTCA to reduce layered testing. Clin Radiol 2023; 78:947-954. [PMID: 37718182 DOI: 10.1016/j.crad.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023]
Abstract
AIM To determine the proportion of computed tomography (CT) coronary angiography (CTCA) referrals with coronary artery calcification (CAC) evident on previous non-cardiac CT imaging and how this impacted the diagnostic yield for CTCA, the requirement for additional diagnostic testing, and the associated costs to confirm or refute obstructive coronary artery disease (CAD). MATERIALS AND METHODS A retrospective review of CTCA examinations was undertaken between 01/05/2018 and 31/05/2020 in which the examinations were cross referenced for previous non-gated thoracic CT at Royal United Hospitals Bath. Major epicardial vessel CAC on baseline CT was re-evaluated by published semi-quantitative methods, giving a per-patient CAC score (mild = 1-3, moderate = 4-6, severe >6). Subsequent incomplete CTCA diagnostic yield, further testing, and cost implications were examined. RESULTS Of the 2140 CTCA examinations identified, 13% (280/2140) had a preceding non-gated thoracic CT (53% female, age 63 ± 11 years). The incomplete diagnostic rate increased with CAC grade, mild 32%, (RR 12; 95% CI 4-40), moderate 64% (RR 25; 95% CI 8-80), severe 75%, (RR 29; 95% CI 9-94). Additional diagnostic testing occurred in 4% for the mild CAC category, and 14% and 42% for moderate and severe, respectively. When severe CAC was identified on a non-gated thoracic CT a cost saving of £171/patient (dobutamine stress echo [DSE]) and £61/patient (myocardial perfusion scintigraphy [MPS]) was established with a direct to functional testing pathway. CONCLUSIONS In patients referred for CTCA where severe CAC was identified on a preceding non-gated thoracic CT a direct to functional testing altered management in 42% of cases and was cost-effective.
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Affiliation(s)
- D Murphy
- Department of Cardiology, Royal United Hospitals Bath, Bath, UK; Department for Health, University of Bath, Bath, UK
| | - J Stephenson
- Department of Cardiology, Royal United Hospitals Bath, Bath, UK
| | - Y Bouhbib
- Department of Radiology, Royal United Hospitals Bath, Bath, UK
| | - J Graby
- Department of Cardiology, Royal United Hospitals Bath, Bath, UK; Department for Health, University of Bath, Bath, UK
| | - A Khavandi
- Department of Cardiology, Royal United Hospitals Bath, Bath, UK
| | - S Lyen
- Department of Radiology, Royal United Hospitals Bath, Bath, UK
| | - B Hudson
- Department of Radiology, Royal United Hospitals Bath, Bath, UK
| | - J C L Rodrigues
- Department for Health, University of Bath, Bath, UK; Department of Radiology, Royal United Hospitals Bath, Bath, UK.
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9
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Alexander M, Lan NSR, Dallo MJ, Briffa TG, Sanfilippo FM, Hooper A, Bartholomew H, Hii L, Hillis GS, McQuillan BM, Dwivedi G, Rankin JM, Ihdayhid AR. Clinical outcomes and health care costs of transferring rural Western Australians for invasive coronary angiography, and a cost-effective alternative care model: a retrospective cross-sectional study. Med J Aust 2023; 219:155-161. [PMID: 37403443 DOI: 10.5694/mja2.52018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/20/2023] [Accepted: 05/10/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES To examine the severity of coronary artery disease (CAD) in people from rural or remote Western Australia referred for invasive coronary angiography (ICA) in Perth and their subsequent management; to estimate the cost savings were computed tomography coronary angiography (CTCA) offered in rural centres as a first line investigation for people with suspected CAD. DESIGN Retrospective cohort study. SETTING, PARTICIPANTS Adults with stable symptoms in rural and remote WA referred to Perth public tertiary hospitals for ICA evaluation during the 2019 calendar year. MAIN OUTCOME MEASURES Severity and management of CAD (medical management or revascularisation); health care costs by care model (standard care or a proposed alternative model with local CTCA assessment). RESULTS The mean age of the 1017 people from rural and remote WA who underwent ICA in Perth was 62 years (standard deviation, 13 years); 680 were men (66.9%), 245 were Indigenous people (24.1%). Indications for referral were non-ST elevation myocardial infarction (438, 43.1%), chest pain with normal troponin level (394, 38.7%), and other (185, 18.2%). After ICA assessment, 619 people were medically managed (60.9%) and 398 underwent revascularisation (39.1%). None of the 365 patients (35.9%) without obstructed coronaries (< 50% stenosis) underwent revascularisation; nine patients with moderate CAD (50-69% stenosis; 7%) and 389 with severe CAD (≥ 70% stenosis or occluded vessel; 75.5%) underwent revascularisation. Were CTCA used locally to determine the need for referral, 527 referrals could have been averted (53%), the ICA:revascularisation ratio would have improved from 2.6 to 1.6, and 1757 metropolitan hospital bed-days (43% reduction) and $7.3 million in health care costs (36% reduction) would have been saved. CONCLUSION Many rural and remote Western Australians transferred for ICA in Perth have non-obstructive CAD and are medically managed. Providing CTCA as a first line investigation in rural centres could avert half of these transfers and be a cost-effective strategy for risk stratification of people with suspected CAD.
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Affiliation(s)
| | - Nick S R Lan
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | | | | | | | - Andrew Hooper
- Medical Royal Flying Doctor Service Western Australia, Perth, WA
| | | | | | - Graham S Hillis
- Royal Perth Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Brendan M McQuillan
- The University of Western Australia, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
| | - Girish Dwivedi
- Fiona Stanley Hospital, Perth, WA
- Harry Perkins Institute of Medical Research, Perth, WA
| | | | - Abdul Rahman Ihdayhid
- Fiona Stanley Hospital, Perth, WA
- Harry Perkins Institute of Medical Research, Perth, WA
- Curtin Medical School, Curtin University, Perth, WA
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10
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Natale L, Vliegenthart R, Salgado R, Bremerich J, Budde RPJ, Dacher JN, Francone M, Kreitner KF, Loewe C, Nikolaou K, Peebles C, Velthuis BK, Catalano C. Cardiac radiology in Europe: status and vision by the European Society of Cardiovascular Radiology (ESCR) and the European Society of Radiology (ESR). Eur Radiol 2023; 33:5489-5497. [PMID: 36905466 PMCID: PMC10006558 DOI: 10.1007/s00330-023-09533-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 03/12/2023]
Abstract
Cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are routine radiological examinations for diagnosis and prognosis of cardiac disease. The expected growth in cardiac radiology in the coming years will exceed the current scanner capacity and trained workforce. The European Society of Cardiovascular Radiology (ESCR) focuses on supporting and strengthening the role of cardiac cross-sectional imaging in Europe from a multi-modality perspective. Together with the European Society of Radiology (ESR), the ESCR has taken the initiative to describe the current status of, a vision for, and the required activities in cardiac radiology to sustain, increase and optimize the quality and availability of cardiac imaging and experienced radiologists across Europe. KEY POINTS: • Providing adequate availability for performing and interpreting cardiac CT and MRI is essential, especially with expanding indications. • The radiologist has a central role in non-invasive cardiac imaging examinations which encompasses the entire process from selecting the best modality to answer the referring physician's clinical question to long-term image storage. • Optimal radiological education and training, knowledge of the imaging process, regular updating of diagnostic standards, and close collaboration with colleagues from other specialties are essential.
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Affiliation(s)
- Luigi Natale
- Department of Radiological Sciences - Institute of Radiology, Catholic University of Rome, "A. Gemelli" University Hospital, Rome, Italy
| | - Rozemarijn Vliegenthart
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Rodrigo Salgado
- Department of Radiology, Antwerp University Hospital & Antwerp University, Holy Heart Lier, Belgium
| | - Jens Bremerich
- Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Riccardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Jean-Nicholas Dacher
- Department of Radiology, Normandie University, UNIROUEN, INSERM U1096 - Rouen University Hospital, Rouen, France
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Karl-Friedrich Kreitner
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Tübingen, Germany
| | - Charles Peebles
- Department of Cardiothoracic Radiology, University Hospital Southampton, Southampton, UK
| | - Birgitta K Velthuis
- Department of Radiology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Carlo Catalano
- Department of Radiological Sciences, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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11
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Johnson CL, Woodward W, McCourt A, Dockerill C, Krasner S, Monaghan M, Senior R, Augustine DX, Paton M, O'Driscoll J, Oxborough D, Pearce K, Robinson S, Willis J, Sharma R, Tsiachristas A, Leeson P. Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study. Echo Res Pract 2023; 10:8. [PMID: 37254216 DOI: 10.1186/s44156-023-00020-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. METHODS Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. RESULTS Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually. CONCLUSION This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.
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Affiliation(s)
- Casey L Johnson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - William Woodward
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Annabelle McCourt
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Cameron Dockerill
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Samuel Krasner
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Mark Monaghan
- Kings College Hospital NHS Foundation Hospital, London, UK
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Hospital, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | | | | | - David Oxborough
- Research Institute for Sports and Exercise Science, Liverpool John Moores University/Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Keith Pearce
- Manchester University NHS Foundation Hospital, Manchester, UK
| | - Shaun Robinson
- North West Anglia NHS Foundation Hospital, Peterborough, UK
| | - James Willis
- Royal United Hospitals Bath NHS Foundation Hospital, Bath, UK
| | - Rajan Sharma
- St. George's University Hospitals NHS Foundation Hospital, London, UK
| | - Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK.
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12
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Madan N, Hur DJ, Gannon MP, Gupta S, Weir-McCall JR, Johns C, Kumar A, Nagpal P, Fentanes E, Lee J, Choi AD, Ferencik M, Maroules CD, Villines TC, Nicol ED. Contemporary cardiovascular computed tomography (CCT) training: Serial surveys of the international CCT community by the Fellow and Resident Leaders of the Society of Cardiovascular Computed Tomography (SCCT) Committee (FiRST) and SCCT Future Leaders Program (FLP). J Cardiovasc Comput Tomogr 2023:S1934-5925(23)00091-6. [PMID: 37015851 DOI: 10.1016/j.jcct.2023.03.006] [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: 11/07/2022] [Revised: 02/28/2023] [Accepted: 03/17/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND As cardiovascular computed tomography (CCT) practice evolves, the demand for specialists continues to increase. However, CCT training remains variable globally with limited contemporaneous data to understand this heterogeneity. We sought to understand the role of CCT globally and the training available to underpin its use. METHODS We performed two consecutive surveys of cardiology and radiology physicians, two years apart, utilizing the Society of Cardiovascular Computed Tomography (SCCT) website, weblinks, social media platforms, and meeting handouts to maximize our response rate. We compared United States (US)-based vs. international responses to understand global similarities and differences in practice and training in the surveys. RESULTS 235 respondents (37% trainees and 63% educators/non-trainees) initiated the first survey with 174 (74%) completing the core survey, with 205 providing their work location (114 US and 91 international). Eighty-four percent (92/110) of educator respondents stated a need for increased training opportunities to meet growing demand. Dedicated training fellowships are heterogenous, with limited access to structural heart imaging training, despite structural scanning being performed within institutions. The lack of a standardized curriculum was identified as the main obstacle to effective CCT learning, particularly in the US, with web-based learning platforms being the most popular option for improving access to CCT training. 148 trainees initiated the second survey with 107 (72%) completing the core components (51% North America, 49% international). Only 68% said they would be able to meet their required CCT education needs via their training program. Obstacles in obtaining CCT training again included a lack of a developed curriculum (51%), a lack of dedicated training time (35%), and a lack of local faculty expertise (31%). There was regional variability in access to CCT training, and, in contrast to the first survey, most (89%) felt 1:1 live review of cases with trained/expert reader was most useful for improving CCT training alongside formal curriculum/live lectures (72%). CONCLUSIONS There is a need to expand dedicated CCT training globally to meet the demand for complex CCT practice. Access to CCT education (didactic and 1:1 case-based teaching from expert faculty), implementation of recently published global training curricula, and increased teaching resources (web-based) as an adjunct to existing experiential learning opportunities, are all deemed necessary to address current educational shortfalls.
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Affiliation(s)
- Nidhi Madan
- Division of Cardiology, Nebraska Methodist Health System, Omaha, NE, USA
| | - David J Hur
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA; Division of Cardiology, VA Connecticut Healthcare System, West Haven, CT, USA.
| | - Michael P Gannon
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Sumit Gupta
- Department of Radiology, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan R Weir-McCall
- School of Clinical Medicine, University of Cambridge, Cambridge, UK; Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - Claire Johns
- Marketing and Communications, Society of Cardiovascular Computed Tomography, Arlington, VA, USA
| | - Arnav Kumar
- Brigham and Women's Hospital, Boston, MA, USA
| | - Prashant Nagpal
- Cardiovascular Imaging, Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | | | - James Lee
- Henry Ford Heart and Vascular Institute, Detroit, MI, USA
| | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | | | - Todd C Villines
- Division of Cardiovascular Medicine, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Edward D Nicol
- Departments of Cardiology and Radiology, Royal Brompton Hospital, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College, London, UK
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13
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Ihdayhid AR, Lan NSR, Figtree GA, Patel S, Arnott C, Hamilton-Craig C, Psaltis PJ, Leipsic J, Fairbairn T, Wahi S, Hillis GS, Rankin JM, Dwivedi G, Nicholls SJ. Contemporary Chest Pain Evaluation: The Australian Case for Cardiac CT. Heart Lung Circ 2023; 32:297-306. [PMID: 36610819 DOI: 10.1016/j.hlc.2022.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/07/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, Curtin University, Perth, WA, Australia.
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sanjay Patel
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Cardiovascular Division, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Peter J Psaltis
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Jonathon Leipsic
- University of British Columbia, St Paul's Hospital, Vancouver, Canada
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Graham S Hillis
- Department of Cardiology and University of Western Australia, Royal Perth Hospital, Perth, WA, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
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14
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Corballis N, Tsampasian V, Merinopoulis I, Gunawardena T, Bhalraam U, Eccleshall S, Dweck MR, Vassiliou V. CT angiography compared to invasive angiography for stable coronary disease as predictors of major adverse cardiovascular events- A systematic review and meta-analysis. Heart Lung 2023; 57:207-213. [PMID: 36257218 DOI: 10.1016/j.hrtlng.2022.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/02/2022] [Accepted: 09/25/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Computational tomography coronary angiography (CTCA) is increasingly the diagnostic test of choice for investigating patients with stable anginal symptoms. OBJECTIVES We sought to conduct a systematic review and meta-analysis comparing CTCA with invasive coronary angiography (ICA) with regards to major adverse cardiovascular events (MACE), procedural complications and rates of revascularisation. METHODS We conducted a systematic review and meta-analysis in line with the PRISMA statement. A literature search was conducted using PubMed, MEDLINE Ovid and Embase, with three studies included in meta-analysis. Statistical analysis was undertaken using Review Manager 5.3 for MacOS software and outcomes expressed as odds ratio, with 95% confidence intervals and sensitivity analysis was conducted. RESULTS A total of 5662 patients were included in this study level meta-analysis. There was no difference in MACE between CT and angiography [2.97% v 3.45%, fixed-effect model, OR: 0.84 (0.62-1.14), p = 0.26, I2 0%] and no difference found in rates of myocardial infarction, death or stroke. CTCA was associated with a reduced rate of revascularisation [12.6% v 18.3%, fixed-effects model, OR: 0.64 (0.55-0.75), p<0.00001, I2 =0%]. However, CTCA was not associated with a significantly lower complication rate [0.5% v 1.72%, random effects model, OR: 0.52 (0.06-4.38), p = 0.55, I2 52%]. CONCLUSION CTCA is a safe strategy for investigating patients with stable angina with no associated increase in MACE but a reduction in revascularisation rates.
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Affiliation(s)
- Natasha Corballis
- Department of cardiology, Norfolk and Norwich University Hospital; Norwich Medical School, University of East Anglia
| | - Vasiliki Tsampasian
- Department of cardiology, Norfolk and Norwich University Hospital; Norwich Medical School, University of East Anglia
| | - Ioannis Merinopoulis
- Department of cardiology, Norfolk and Norwich University Hospital; Norwich Medical School, University of East Anglia
| | - Tharusha Gunawardena
- Department of cardiology, Norfolk and Norwich University Hospital; Norwich Medical School, University of East Anglia
| | - U Bhalraam
- Department of cardiology, Norfolk and Norwich University Hospital; Norwich Medical School, University of East Anglia
| | - Simon Eccleshall
- Department of cardiology, Norfolk and Norwich University Hospital
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Vassilios Vassiliou
- Department of cardiology, Norfolk and Norwich University Hospital; Norwich Medical School, University of East Anglia.
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15
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Hu MK, Yuan M, James S, Lee HP, Abdul F, Yousif A, Hassan A, Khan J, Connolly D, Sharma V. Positive remodelling of coronary arteries on computed tomography coronary angiogram: an observational study. ASIAINTERVENTION 2022; 8:110-115. [PMID: 36483287 PMCID: PMC9706778 DOI: 10.4244/aij-d-21-00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/12/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) due to atherosclerosis is projected to be the leading cause of morbidity and mortality worldwide until 2040. CAD affects approximately 2.6 million people in the United Kingdom (UK), and 1 in 4 of them do not experience any symptoms. AIMS The aim of this study was to assess the characteristics and outcomes of patients with plaque features of positive remodelling (PR) on their computed tomography coronary angiogram (CTCA) images. METHODS Patients who were referred for CTCA from June 2018 to January 2020 were retrospectively identified. Patients underwent prospective, gated 128-slice dual-source CTCA. Patients with PR were compared to those without PR for demographics and outcomes. RESULTS A total of 861 patients were included in our study; 241 (28%) had PR, and 620 (72%) had no PR. Patients with PR were older (PR: 63.9±11.0 years vs no PR: 62.1±11.2 years; p=0.04), more likely to be male (PR: 65.6% vs no PR: 55.8%; p=0.01) and underwent coronary angiography more frequently (PR: 25.7% vs no PR: 14.4%; p<0.01). There were also significant increases in subsequent acute coronary syndrome (ACS) events (PR: 2.5% vs no PR: 0.0%; p<0.01) and the need for revascularisation therapy (PR: 15.4% vs no PR: 7.8%; p<0.01) in patients with PR despite being on statins (not a high dose). There was no difference in all-cause mortality. CONCLUSIONS Detection of PR on CTCA is a reliable prognostic indicator of future cardiovascular events and presents a valuable opportunity for initiation of aggressive primary prevention therapy.
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Affiliation(s)
- May Khei Hu
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Mengshi Yuan
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Sunil James
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Hui Ping Lee
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Fairoz Abdul
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Abdel Yousif
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Ahmed Hassan
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Jawad Khan
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
| | - Derek Connolly
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Vinoda Sharma
- Department of Cardiology, Birmingham City Hospital, Birmingham, United Kingdom
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16
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Villines TC. Improving education and training opportunities in cardiac CT. J Cardiovasc Comput Tomogr 2022; 16:384-385. [DOI: 10.1016/j.jcct.2022.05.008] [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: 11/27/2022]
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17
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Treibel TA, Kelion A, Ingram TE, Archbold RA, Myerson SG, Menezes LJ, Morgan-Hughes GJ, Schofield R, Keenan NG, Clarke SC, Keys A, Keogh B, Masani N, Ray S, Westwood M, Pearce K, Colebourn CL, Bull RK, Greenwood JP, Roditi GH, Lloyd G. United Kingdom standards for non-invasive cardiac imaging: recommendations from the Imaging Council of the British Cardiovascular Society. Heart 2022; 108:e7. [PMID: 35613713 DOI: 10.1136/heartjnl-2022-320799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.
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Affiliation(s)
- Thomas A Treibel
- Cardiac Imaging, Saint Bartholomew's Hospital Barts Heart Centre, London, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Andrew Kelion
- Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - R Andrew Archbold
- General & Invasive Cardiology, Saint Bartholomew's Hospital Barts Heart Centre, London, UK
| | - Saul G Myerson
- Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Leon J Menezes
- Department of Nuclear Cardiology, Barts Health NHS Trust, London, London, UK
| | | | - Rebecca Schofield
- Department of Cardiology, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Niall G Keenan
- Department of Cardiology, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Sarah C Clarke
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Bruce Keogh
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Navroz Masani
- Department of Cardiology, Cardiff and Vale NHS Trust, Cardiff, Cardiff, UK
| | - Simon Ray
- Cardiology, University Hospitals of South Manchester, Manchester, UK
| | - Mark Westwood
- Department of Cardiac Imaging, Bart's Heart Centre, St Bartholomew's Hospital, London, UK
| | - Keith Pearce
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | | | | | - John Pierre Greenwood
- Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Biomedical Imaging Sciences, University of Leeds, Leeds, UK
| | - Giles H Roditi
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Guy Lloyd
- Department of Cardiac Imaging, Bart's Heart Centre, St Bartholomew's Hospital, London, UK
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18
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Blankstein R, Shaw LJ, Gulati M, Atalay MK, Bax J, Calnon DA, Dyke CK, Ferencik M, Heitner JF, Henry TD, Hung J, Knuuti J, Lindner JR, Phillips LM, Raman SV, Rao SV, Rybicki FJ, Saraste A, Stainback RF, Thompson RC, Williamson E, Nieman K, Tremmel JA, Woodard PK, Di Carli MF, Chandrashekhar YS. Implications of the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline for Cardiovascular Imaging: A Multisociety Viewpoint. JACC Cardiovasc Imaging 2022; 15:912-926. [PMID: 35512960 DOI: 10.1016/j.jcmg.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Leslee J Shaw
- Departments of Medicine (Cardiology) and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michael K Atalay
- Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Jeroen Bax
- Heart Center, Turku University Hospital, Turku, Finland; Leiden University Medical Centre, Leiden, the Netherlands
| | - Dennis A Calnon
- Ohio Health Heart & Vascular Physicians, Columbus, Ohio, USA
| | | | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juhani Knuuti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Subha V Raman
- Indiana University CV Institute and Krannert CV Research Center, Indianapolis, Indiana, USA
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Frank J Rybicki
- University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Antti Saraste
- Heart Center, Turku University Hospital, Turku, Finland; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Raymond F Stainback
- Texas Heart Institute and Baylor College of Medicine, Division of Cardiology, Houston, Texas, USA
| | - Randall C Thompson
- St. Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Koen Nieman
- Stanford University, Palo Alto, California, USA
| | | | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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19
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Hofmann BM, Gransjøen AM. Geographical variations in the use of outpatient diagnostic imaging in Norway 2019. Acta Radiol Open 2022; 11:20584601221074561. [PMID: 35251700 PMCID: PMC8891857 DOI: 10.1177/20584601221074561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Geographical variations in the use of outpatient imaging can reveal inappropriate use of radiological services. Knowledge about these variations is crucial in the strive for appropriate and improved services. Purpose To investigate the geographical variations in outpatient diagnostic imaging and analyze variations for main groups of examinations and for specific examinations. Material and methods Data on outpatient radiological procedures registered at the Norwegian Health Economics Administration in Norway for 2019 were accessed with county-based population rates for age adjustment accessed through Statistics Norway. Age-adjusted rates were used to calculate high/low ratios, means, standard deviations, and coefficients of variation were calculated per 10,000 inhabitants. Results There is high geographical variation for PET/CT and PET/MRI and moderate variation for neuroradiological outpatient examinations in Norway in 2019. Variations for the musculoskeletal systems and of thorax, abdomen, and vessels are almost 50%. We find high high-to-low ratios in CT—face (9.7), MRI—elbow joint (8.5), CT of the neck, thorax, abdomen, and pelvis (6.5) as well as MRI—prostate (6.2). Comparing with data from 2012–5, we find a reduction in variation for some examinations, such as MRI of the hip and MRI of the entire spine, and an increase in variations for others, such as CT of the face and MRI of the elbow joint. Conclusion Despite much attention to the problem, we demonstrate substantial variations in radiological services in Norway raising concern with respect to appropriateness, quality of care, equity, and justice. The findings provide important input for quality improvement in radiological services.
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Affiliation(s)
- Bjørn M Hofmann
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
| | - Ann M Gransjøen
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
- SHARE, University of Stavanger, Stavanger, Norway
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20
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van den Boogert TPW, Claessen BEPM, Boekholdt SM, Leiner T, Vliegenthart R, Schuiling SF, Timmer JR, Bekkers SCAM, Voskuil M, Siebelink HJ, van Es W, Lamb HJ, Prokop M, Damman P, Stoker J, Willems HC, Henriques JP, Planken RN. The impact and challenges of implementing CTCA according to the 2019 ESC guidelines on chronic coronary syndromes: a survey and projection of CTCA services in the Netherlands. Insights Imaging 2021; 12:186. [PMID: 34921633 PMCID: PMC8684565 DOI: 10.1186/s13244-021-01122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background The 2019 ESC-guidelines on chronic coronary syndromes (ESC-CCS) recommend computed tomographic coronary angiography (CTCA) or non-invasive functional imaging instead of exercise ECG as initial test to diagnose obstructive coronary artery disease. Since impact and challenges of these guidelines are unknown, we studied the current utilisation of CTCA-services, status of CTCA-protocols and modeled the expected impact of these guidelines in the Netherlands. Methods and results A survey on current practice and CTCA utilisation was disseminated to every Dutch hospital organisation providing outpatient cardiology care and modeled the required CTCA capacity for implementation of the ESC guideline, based on these national figures and expert consensus. Survey response rate was 100% (68/68 hospital organisations). In 2019, 63 hospital organisations provided CTCA-services (93%), CTCA was performed on 99 CTCA-capable CT-scanners, and 37,283 CTCA-examinations were performed. Between the hospital organisations, we found substantial variation considering CTCA indications, CTCA equipment and acquisition and reporting standards. To fully implement the new ESC guideline, our model suggests that 70,000 additional CTCA-examinations would have to be performed in the Netherlands. Conclusions Despite high national CTCA-services coverage in the Netherlands, a substantial increase in CTCA capacity is expected to be able to implement the 2019 ESC-CCS recommendations on the use of CTCA. Furthermore, the results of this survey highlight the importance to address variations in image acquisition and to standardise the interpretation and reporting of CTCA, as well as to establish interdisciplinary collaboration and organisational alignment.
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Affiliation(s)
- T P W van den Boogert
- Heart centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - B E P M Claessen
- Heart centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - S M Boekholdt
- Heart centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - T Leiner
- Department of Radiology, Utrecht University Medical centre, Utrecht, The Netherlands
| | - R Vliegenthart
- Department of Radiology, University Medical centre Groningen, Groningen, The Netherlands
| | - S F Schuiling
- Zorgevaluatie en Gepast Gebruik, Diemen, The Netherlands
| | - J R Timmer
- Departments of Cardiology, Isala, Zwolle, The Netherlands
| | - S C A M Bekkers
- Department of Cardiology, Maastricht University Medical centre, Maastricht, The Netherlands
| | - M Voskuil
- Department of Cardiology, Utrecht University Medical centre, Utrecht, The Netherlands
| | - H J Siebelink
- Department of Cardiology, Leiden University Medical centre, Leiden, The Netherlands
| | - W van Es
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - H J Lamb
- Department of Radiology, Leiden University Medical centre, Leiden, The Netherlands
| | - M Prokop
- Department of Radiology, Nuclear Medicine, and Anatomy, Radboud University Medical centre, Nijmegen, The Netherlands
| | - P Damman
- Department of Cardiology, Radboud University Medical centre, Nijmegen, The Netherlands
| | - J Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H C Willems
- Division of Geriatrics, Department of Internal Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - J P Henriques
- Heart centre, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R N Planken
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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21
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Shaikh KA, Walters RW, Aboeata A, Thandra A, Anugula D, Urja P, Alla VM, Budoff MJ. Trends in utilization of Coronary CT Angiography in patients presenting with acute chest pain in United States: An analysis of the National Emergency Database. J Cardiovasc Comput Tomogr 2021; 16:277-278. [PMID: 34844899 DOI: 10.1016/j.jcct.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Kashif A Shaikh
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA; Harbor-UCLA Medical Center, Department of Internal Medicine, Division of Cardiology, USA.
| | - Ryan W Walters
- Creighton University School of Medicine, Department of Medicine, Division of Clinical Research and Evaluative Sciences, USA
| | - Ahmed Aboeata
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Abhishek Thandra
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Dixitha Anugula
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Prakrity Urja
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Venkata M Alla
- Creighton University School of Medicine, Department of Medicine, Division of Cardiology, USA
| | - Matthew J Budoff
- Harbor-UCLA Medical Center, Department of Internal Medicine, Division of Cardiology, USA
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22
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Dreisbach JG, Rodrigues JC, Roditi G. Emergency CT misdiagnosis in acute aortic syndrome. Br J Radiol 2021; 94:20201294. [PMID: 34491770 DOI: 10.1259/bjr.20201294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This cross-sectional study assessed the accuracy of emergency CT reports at presentation in acute aortic syndrome (AAS). METHODS Retrospective identification of cases of AAS presenting within a large health board with three acute hospitals receiving adult patients between January 2013 and December 2016. CT studies and reports at presentation were reviewed for discrepancies related to diagnosis, complications and classification by two cardiovascular radiologists. The specialist interest of the original reporters, clinically suspected diagnosis at referral for CT and technical adequacy of the scans were also assessed. False-positive diagnoses were identified and evaluated separately. RESULTS Among 88 consecutive confirmed cases of AAS at least one discrepancy was identified in 31% (n = 27), including failure to identify or misinterpretation of the AAS itself in 15% (n = 13), haemorrhage in 13% (n = 11), branch involvement in 9% (n = 8), and misclassification in 3% (n = 3). All discrepancies occurred among the 80% (n = 70) of cases reported by radiologists without specialist cardiovascular interest. 26% (n = 23/88) of AAS cases were not clinically suspected at referral for CT and although this was associated with suboptimal protocols, only 51% of CT scans among suspected cases were technically adequate. Seven false-positive diagnoses were identified, three of which related to motion artefact. CONCLUSION Significant discrepancies are common in the emergency CT assessment of positive cases AAS and this study highlights important pitfalls in CT technique and interpretation. The absence of discrepancies among radiologists with specialist cardiovascular interest suggests both suspected and confirmed cases warrant urgent specialist review. ADVANCES IN KNOWLEDGE CT angiography is central to the diagnosis of AAS; however, significant radiology discrepancies are common among non-specialists. This study highlights important pitfalls in both CT technique as well as interpretation and supports routine specialist cardiovascular imaging input in the emergency assessment of AAS.
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Affiliation(s)
- John G Dreisbach
- Department of Radiology, Golden Jubilee National Hospital, Clydebank, United Kingdom.,Department of Radiology, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jonathan Cl Rodrigues
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
| | - Giles Roditi
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, United Kingdom
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23
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Oikonomou EK, Siddique M, Antoniades C. Artificial intelligence in medical imaging: A radiomic guide to precision phenotyping of cardiovascular disease. Cardiovasc Res 2021; 116:2040-2054. [PMID: 32090243 DOI: 10.1093/cvr/cvaa021] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/29/2019] [Accepted: 01/23/2020] [Indexed: 12/23/2022] Open
Abstract
ABSTRACT Rapid technological advances in non-invasive imaging, coupled with the availability of large data sets and the expansion of computational models and power, have revolutionized the role of imaging in medicine. Non-invasive imaging is the pillar of modern cardiovascular diagnostics, with modalities such as cardiac computed tomography (CT) now recognized as first-line options for cardiovascular risk stratification and the assessment of stable or even unstable patients. To date, cardiovascular imaging has lagged behind other fields, such as oncology, in the clinical translational of artificial intelligence (AI)-based approaches. We hereby review the current status of AI in non-invasive cardiovascular imaging, using cardiac CT as a running example of how novel machine learning (ML)-based radiomic approaches can improve clinical care. The integration of ML, deep learning, and radiomic methods has revealed direct links between tissue imaging phenotyping and tissue biology, with important clinical implications. More specifically, we discuss the current evidence, strengths, limitations, and future directions for AI in cardiac imaging and CT, as well as lessons that can be learned from other areas. Finally, we propose a scientific framework in order to ensure the clinical and scientific validity of future studies in this novel, yet highly promising field. Still in its infancy, AI-based cardiovascular imaging has a lot to offer to both the patients and their doctors as it catalyzes the transition towards a more precise phenotyping of cardiovascular disease.
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Affiliation(s)
- Evangelos K Oikonomou
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.,Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Musib Siddique
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.,Caristo Diagnostics Ltd., Oxford, UK
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.,Oxford Centre of Research Excellence, British Heart Foundation, Oxford, UK.,Oxford Biomedical Research Centre, National Institute of Health Research, Oxford, UK
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24
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Kite TA, Ladwiniec A, Arnold JR, McCann GP, Moss AJ. Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome. Heart 2021; 108:500-506. [PMID: 34234006 DOI: 10.1136/heartjnl-2020-318778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/22/2021] [Indexed: 11/04/2022] Open
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) comprises a broad spectrum of disease ranging from unstable angina to myocardial infarction. International guidelines recommend a routine invasive strategy for managing patients with NSTE-ACS at high to very high-risk, supported by evidence of improved composite ischaemic outcomes as compared with a selective invasive strategy. However, accurate diagnosis of NSTE-ACS in the acute setting is challenging due to the spectrum of non-coronary disease that can manifest with similar symptoms. Heterogeneous clinical presentations and limited uptake of risk prediction tools can confound physician decision-making regarding the use and timing of invasive coronary angiography (ICA). Large proportions of patients with suspected NSTE-ACS do not require revascularisation but may unnecessarily undergo ICA with its attendant risks and associated costs. Advances in coronary CT angiography and cardiac MRI have prompted evaluation of whether non-invasive strategies may improve patient selection, or whether tailored approaches are better suited to specific subgroups. Future directions include (1) better understanding of risk stratification as a guide to investigation and therapy in suspected NSTE-ACS, (2) randomised clinical trials of non-invasive imaging versus standard of care approaches prior to ICA and (3) defining the optimal timing of very early ICA in high-risk NSTE-ACS.
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Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Ranjit Arnold
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alastair J Moss
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
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25
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Berry C, Morrow AJ, Marzilli M, Pepine CJ. What Is the Role of Assessing Ischemia to Optimize Therapy and Outcomes for Patients with Stable Angina and Non-obstructed Coronary Arteries? Cardiovasc Drugs Ther 2021; 36:1027-1038. [PMID: 33978865 PMCID: PMC9519699 DOI: 10.1007/s10557-021-07179-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 01/09/2023]
Abstract
Ischemic heart disease (IHD) is a leading global cause of ill-health and premature death. Clinical research into IHD is providing new insights into the pathophysiology, epidemiology and treatment of this condition. The major endotypes of IHD include coronary heart disease (CHD) and vasomotor disorders, including microvascular angina and vasospastic angina. Considering unselected patients presenting with stable chest pain, the pre-test probability of CHD is higher in men whereas the pre-test probability of a vasomotor disorder is higher in women. The diagnostic accuracy of diagnostic tests designed to assess coronary anatomy and disease and/or coronary vascular function (functional tests) differ for coronary endotypes. Clinical management should therefore be personalized and take account of sex-related factors. In this review, we consider the definitions of angina and myocardial ischemia. We then appraise the mechanistic links between myocardial ischemia and anginal symptoms and the relative merits of non-invasive and invasive diagnostic tests and related clinical management. Finally, we describe the rationale and importance of stratified medicine of IHD.
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Affiliation(s)
- Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
- Golden Jubilee National Hospital, Clydebank, UK.
| | - Andrew J Morrow
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Golden Jubilee National Hospital, Clydebank, UK
| | - Mario Marzilli
- Division of Cardiovascular Medicine, Cardiothoracic Department, Pisa University Medical School, Pisa, Italy
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
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Cronin M, Wheen P, Armstrong R, Kumar R, McMahon A, White M, Sheehy N, McMahon G, Murphy RT, Daly C. CT coronary angiography and COVID-19: inpatient use in acute chest pain service. Open Heart 2021; 8:openhrt-2020-001548. [PMID: 33731419 PMCID: PMC7976674 DOI: 10.1136/openhrt-2020-001548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/03/2021] [Accepted: 03/05/2021] [Indexed: 12/04/2022] Open
Abstract
Objectives CT coronary angiography (CTCA) is a well-validated clinical tool in the evaluation of chest pain. In our institution, CTCA availability was increased in January 2020, and subsequently, expanded further to replace all exercise testing during the COVID-19 pandemic. Our objective was to assess the impact of increased utilisation of CTCA on length of stay in patients presenting with chest pain in the prepandemic era and during the COVID-19 pandemic. Methods Study design was retrospective. Patients referred for cardiology review between October 2019 and May 2020 with chest pain and/or dyspnoea were broken into three cohorts: a baseline cohort, a cohort with increased CTCA availability and a cohort with increased CTCA availability, but after the national lockdown due to COVID-19. Coronary angiography and revascularisation, length of stay and 30-day adverse outcomes were assessed. Results 513 patients (35.3% female) presented over cohorts 1 (n=179), 2 (n=182), and 3 (n=153). CTCA use increased from 7.8% overall in cohort 1% to 20.4% in cohort 3. Overall length of stay for the patients undergoing CTCA decreased from a median of 4.2 days in cohort 1 to 2.5 days in cohort 3, with no increase in 30 days adverse outcomes. Invasive coronary angiogram rates were 45.8%, 39% and 34.2% across the cohorts. 29.6% underwent revascularisation in cohort 1, 15.9% in cohort 2 and to 16.4% in cohort 3. Conclusions Increased CTCA availability was associated with a significantly reduced length of stay both pre-COVID-19 and post-COVID-19 lockdown, without any increase in 30-day adverse outcomes.
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Affiliation(s)
| | - Peter Wheen
- Cardiology, Saint James's Hospital, Dublin, Ireland
| | | | - Rajesh Kumar
- Cardiology, Saint James's Hospital, Dublin, Ireland
| | | | - Max White
- Medicine, Trinity College Dublin, Dublin, Ireland
| | - Niall Sheehy
- Radiology, Saint James's Hospital, Dublin, Ireland
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Keenan NG, Captur G, McCann GP, Berry C, Myerson SG, Fairbairn T, Hudsmith L, O'Regan DP, Westwood M, Greenwood JP. Regional variation in cardiovascular magnetic resonance service delivery across the UK. Heart 2021; 107:1974-1979. [PMID: 33766986 PMCID: PMC8639953 DOI: 10.1136/heartjnl-2020-318667] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/16/2021] [Accepted: 02/20/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine service provision in cardiovascular magnetic resonance (CMR) in the UK. Equitable access to diagnostic imaging is important in healthcare. CMR is widely available in the UK, but there may be regional variations. METHODS An electronic survey was sent by the British Society of CMR to the service leads of all CMR units in the UK in 2019 requesting data from 2017 and 2018. Responses were analysed by region and interpreted alongside population statistics. RESULTS The survey response rate was 100% (82 units). 100 386 clinical scans were performed in 2017 and 114 967 in 2018 (15% 1-year increase; 5-fold 10-year increase compared with 2008 data). In 2018, there were 1731 CMR scans/million population overall, with significant regional variation, for example, 4256 scans/million in London vs 396 scans/million in Wales. Median number of clinical scans per unit was 780, IQR 373-1951, range 98-10 000, with wide variation in mean waiting times (median 41 days, IQR 30-49, range 5-180); median 25 days in London vs 180 days in Northern Ireland). Twenty-five units (30%) reported mean elective waiting times in excess of 6 weeks, and 8 (10%) ≥3 months. There were 351 consultants reporting CMR, of whom 230 (66%) were cardiologists and 121 (34%) radiologists; 81% of units offered a CMR service for patients with pacemakers and defibrillators. CONCLUSIONS This survey provides a unique, contemporary insight into national CMR delivery with 100% centre engagement. The 10-year growth in CMR usage at fivefold has been remarkable but heterogeneous across the UK, with some regions still reporting low usage or long waiting times which may be of clinical concern.
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Affiliation(s)
- Niall G Keenan
- Cardiology, West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK .,MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Gabriella Captur
- University College London Institute of Cardiovascular Science, London, UK.,Centre for Inherited Heart Muscle Conditions, Royal Free Hospital, London, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Cardiology, Golden Jubilee National Hospital, Clydebank, UK
| | - Saul G Myerson
- University of Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy Fairbairn
- Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, Merseyside, UK
| | - Lucy Hudsmith
- Adult Congenital Heart Disease Unit, University Hospitals Birmingham, Birmingham, West Midlands, UK
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | | | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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28
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Choi AD, Thomas DM, Lee J, Abbara S, Cury RC, Leipsic JA, Maroules C, Nagpal P, Steigner ML, Wang DD, Williams MC, Zeb I, Villines TC, Blankstein R. 2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography. Radiol Cardiothorac Imaging 2021; 3:e200480. [PMID: 33778658 PMCID: PMC7978013 DOI: 10.1148/ryct.2020200480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Cardiovascular computed tomography (CCT) is a well-validated noninvasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT. This article is being published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, and JACC: Cardiovascular Imaging. © 2020 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.
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Choi AD, Ferencik M, Leipsic J, Williams MC, Villines TC. Training and competency in cardiovascular computed tomography: Collaborative paradigm for the rising tide. J Cardiovasc Comput Tomogr 2021; 15:88-90. [PMID: 33281096 DOI: 10.1016/j.jcct.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andrew D Choi
- Division of Cardiology & Department of Radiology, The George Washington University, School of Medicine, Washington, DC, United States.
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, United States
| | - Jonathon Leipsic
- Departments of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Todd C Villines
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, United States
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30
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Choi AD, Thomas DM, Lee J, Abbara S, Cury RC, Leipsic JA, Maroules C, Nagpal P, Steigner ML, Wang DD, Williams MC, Zeb I, Villines TC, Blankstein R. 2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021; 15:2-15. [PMID: 33032977 PMCID: PMC7427549 DOI: 10.1016/j.jcct.2020.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.
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Affiliation(s)
- Andrew D Choi
- Division of Cardiology & Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA.
| | | | - James Lee
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, MI, USA
| | - Suhny Abbara
- Division of Cardiothoracic Imaging, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ricardo C Cury
- Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, FL and Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Michael L Steigner
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Dee Dee Wang
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, MI, USA
| | - Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Irfan Zeb
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, MA, USA
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Choi AD, Thomas DM, Lee J, Abbara S, Cury RC, Leipsic JA, Maroules C, Nagpal P, Steigner ML, Wang DD, Williams MC, Zeb I, Villines TC, Blankstein R. 2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography. JACC Cardiovasc Imaging 2021; 14:272-287. [PMID: 33168479 DOI: 10.1016/j.jcmg.2020.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.
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Affiliation(s)
- Andrew D Choi
- Division of Cardiology & Department of Radiology, The George Washington University School of Medicine, Washington, DC.
| | | | - James Lee
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan
| | - Suhny Abbara
- Division of Cardiothoracic Imaging, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ricardo C Cury
- Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, Florida and Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael L Steigner
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dee Dee Wang
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Center for Structural Heart Disease, Detroit, Michigan
| | - Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Irfan Zeb
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
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32
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Cho MS, Roh JH, Park H, Cho SC, Kang DY, Lee PH, Ahn JM, Koo HJ, Yang DH, Kang JW, Park SJ, Patel MR, Park DW. Practice Pattern, Diagnostic Yield, and Long-Term Prognostic Impact of Coronary Computed Tomographic Angiography. J Am Heart Assoc 2020; 9:e016620. [PMID: 32896194 PMCID: PMC7726974 DOI: 10.1161/jaha.120.016620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Although guidelines recommend the use of coronary computed tomographic angiography (CTA) in patients with stable pain syndromes, the clinical benefits of the use of coronary CTA in a broad spectrum of patients is unknown. We evaluated the contemporary practice pattern and diagnostic yield of coronary CTA and their impact on the subsequent diagnostic-therapeutic cascade and clinical outcomes. Methods and Results We identified 39 906 patients without known coronary artery disease (CAD) who underwent coronary CTA between January 2007 and December 2013. The patients' demographic characteristics, risk factors, symptoms, results of coronary CTA, the appropriateness of downstream diagnostic and therapeutic interventions, and long-term outcomes (death or myocardial infarction) were evaluated. The number of coronary CTAs had increased over time, especially in asymptomatic patients. Coronary CTA revealed that 6108 patients (15.3%) had obstructive CAD (23.7% of symptomatic and 9.3% of asymptomatic patients). Subsequent cardiac catheterization was performed in 19.2% of symptomatic patients (appropriate, 80.6%) and in 3.9% of asymptomatic patients (appropriate, 7.9%). The 5-year rate of death or myocardial infarction was significantly higher in patients with obstructive CAD on CTA than those without (7.2% versus 3.0%; P<0.001; adjusted hazard ratio [95% CI], 1.34 [1.17-1.54]). However, obstructive CAD on CTA had limited added value over conventional risk factors for predicting death or myocardial infarction. Conclusions Although the use of coronary CTA had substantially increased, CTA had a low diagnostic yield for obstructive CAD, especially in asymptomatic patients. The use of CTA in asymptomatic patients seemed to have led to inappropriate subsequent diagnostic or therapeutic interventions without clinical benefit.
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Affiliation(s)
- Min Soo Cho
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Jae-Hyung Roh
- Department of Cardiology Chungnam National University Hospital Daejeon Korea
| | - Hanbit Park
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Sang-Cheol Cho
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Do-Yoon Kang
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Pil Hyung Lee
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Jung-Min Ahn
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Seung-Jung Park
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Manesh R Patel
- Duke Clinical Research Institute Duke University Durham NC
| | - Duk-Woo Park
- Department of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
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Radiological outpatient' visits to avoid inappropriate cardiac CT examinations: an 8-year experience report. Radiol Med 2020; 126:214-220. [PMID: 32651776 DOI: 10.1007/s11547-020-01246-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to evaluate the appropriateness of the cardiac computed tomography angiography (CCTA) prescriptions according to the "2010-Appropriate-Use-Criteria-for-Cardiac-Computed-Tomography-Angiography" (AUCCTA) and "Clinical-indication-for-CCTA" (CICCTA) among different specialities (Cardiologist [CA], General Practitioner [GP], Other Specialists [OS]) and prescribers' age. MATERIALS AND METHODS This is a single-centre, single-arm, cohort study. We prospectively enrolled 815 patients (October 2012-May 2019) who underwent a radiological outpatient visit, before CCTA examination. Prescriptions to the examination were categorized as follows: Appropriate (A), Uncertain (U) and Inappropriate (Ina), according to AUCCTA and I, II, III and Inv for CICCTA. This categorization was stratified according to CA, GP and OS and prescribers' age. CCTA was performed in patients whom indications belong to A/U categories. RESULTS Eight hundred and fifteen CCTA prescriptions were analysed. An yearly increase in prescriptions was found in the eight-year observational period (2012/2019 projection: 72 vs 223). Considering AUCCTA, indication A was 540/815 (66.3%), indication U was 113/815 (13.9%) and Ina accounted for 162/815 (19.9%; 128/162 [79.0%] indications with stress test listed as criterium of inappropriateness). Only U indications decreased over years (p = 0.003). Regarding CICCTA, 501/815 (61.5%) patients were categorized as I, 144/815 (17.7%) as II, 102/815 (12.5%) as III, 67/815 (8.2%) were INV and 1/815 (0.1%) were non-classified. Clinical referrals were CA in 495/786 (63.0%), GPs in 57/786 (7.3%) GP and OS in 234/786 (29.8%) [p < 0.01]. No statistically significant differences were observed in the appropriateness among different specialty physicians. Younger doctors have a lower chance to not meet A indication (OR 0.98 [CI 95% 0.96-0.99]; p = 0.003). CONCLUSION Our study highlights the importance of a pre-radiological visit prior to CCTA, which prevented execution of 19.9% of inappropriate examinations. Age of prescribers had an impact on appropriateness, with younger doctors having a lower chance to not meet A indication.
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Harries I, Weir-McCall JR, Williams MC, Shambrook J, Roditi G, Bull R, Morgan-Hughes GJ, Nicol ED, Moss AJ. CT imaging prior to transcatheter aortic valve implantation in the UK. Open Heart 2020; 7:e001233. [PMID: 32518659 PMCID: PMC7254150 DOI: 10.1136/openhrt-2019-001233] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/25/2020] [Accepted: 02/17/2020] [Indexed: 11/09/2022] Open
Abstract
Objective This cross-sectional observational study sought to describe variations in CT in the context of transcatheter aortic valve implantation (CT-TAVI) as currently performed in the UK. Methods 408 members of the British Society of Cardiovascular Imaging were invited to complete a 27-item online CT-TAVI survey. Results 47 responses (12% response rate) were received from 40 cardiac centres, 23 (58%) of which performed TAVI on-site (TAVI centres). Only six respondents (13%) performed high-volume activity (>200 scans per year) compared with 13 (28%) performing moderate (100–200 scans per year) and 27 (59%) performing low (0–99 scans per year) volume activity. Acquisition protocols varied (41% retrospective, 12% prospective with wide padding, 47% prospective with narrow padding), as did the phase of reporting (45% systolic, 37% diastolic, 11% both, 6% unreported). Median dose length product was 675 mGy.cm (IQR 477–954 mGy.cm). Compared with non-TAVI centres, TAVI centres were more likely to report minimum iliofemoral luminal diameter (n=25, 96% vs n=7, 58%, p=0.003) and optimal tube angulation for intervention (n=12, 46% vs n=1, 8%, p=0.02). Conclusions This national survey formally describes current CT-TAVI practice in the UK. High-volume activity was only present at one in seven cardiac CT centres. There is wide variation in scan acquisition, scan reporting and radiation dose exposure in cardiac CT centres.
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Affiliation(s)
- Iwan Harries
- Cardiology, Bristol Heart Institute, Bristol, UK
| | | | - Michelle C Williams
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, Lothian, UK
| | - James Shambrook
- Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Russel Bull
- Radiology, Royal Bournemouth Hospital, Bournemouth, UK
| | | | - Edward D Nicol
- Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Alastair J Moss
- University of Edinburgh Centre for Cardiovascular Sciences, Edinburgh, UK
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35
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Asher A, Ghelani R, Thornton G, Rathod K, Jones D, Wragg A, Timmis A. UK perspective on the changing landscape of non-invasive cardiac testing. Open Heart 2019; 6:e001186. [PMID: 31908814 PMCID: PMC6927513 DOI: 10.1136/openhrt-2019-001186] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To document UK rates of exercise treadmill testing, functional stress testing and CT coronary angiography (CTCA). Specific aims were to determine how rates have changed in the context of changing guideline recommendations within the UK and to identify regional inequalities in the utilisation of testing modalities. Secondary objectives were to compare these trends with national data on revascularisation. Methods 159 acute National Health Service trusts were served Freedom of Information (FOI) requests to provide total numbers of CTCA and functional imaging tests for each financial year from 2011–2012 to 2016–2017. Results The FOI requests yielded data from 88% of Trusts, increasing from 81.9% in 2011–2012% to 92.1% in 2016–2017. Exercise treadmill tests (ETTs) were performed by over 97% of Trusts. ETT was the most commonly performed diagnostic test in the UK across the study period despite declining by 8.4%. Utilisation of non-invasive stress imaging tests increased by 80.9% during the same period. Myocardial perfusion scintigraphy and stress echocardiography increased by 25.8% and 73.9%, respectively. The 268% increase in CTCA scans was yet greater. Trends in test utilisation during the study period showed important regional differences between devolved nations. Comparably, only small changes in rates of invasive coronary angiography and revascularisation have been reported during the study period. Conclusion Non-invasive imaging in UK Trusts has increased substantially since 2010 with only a small decline in use of the ETT and minimal changes in rates of invasive coronary angiography and revascularisation in the same time period.
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Affiliation(s)
- Alex Asher
- Cardiology, Barts Health NHS Trust, London, UK
| | | | | | | | - Daniel Jones
- Cardiology, Barts Health NHS Trust, London, UK.,Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK
| | - Andrew Wragg
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
| | - Adam Timmis
- Faculty of Medicine and Dentistry, Barts and The London School of Medicine and Dentistry Postgraduate Studies, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
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Hampe N, Wolterink JM, van Velzen SGM, Leiner T, Išgum I. Machine Learning for Assessment of Coronary Artery Disease in Cardiac CT: A Survey. Front Cardiovasc Med 2019; 6:172. [PMID: 32039237 PMCID: PMC6988816 DOI: 10.3389/fcvm.2019.00172] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/12/2019] [Indexed: 01/10/2023] Open
Abstract
Cardiac computed tomography (CT) allows rapid visualization of the heart and coronary arteries with high spatial resolution. However, analysis of cardiac CT scans for manifestation of coronary artery disease is time-consuming and challenging. Machine learning (ML) approaches have the potential to address these challenges with high accuracy and consistent performance. In this mini review, we present a survey of the literature on ML-based analysis of coronary artery disease in cardiac CT. We summarize ML methods for detection and characterization of atherosclerotic plaque as well as anatomically and functionally significant coronary artery stenosis.
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Affiliation(s)
- Nils Hampe
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jelmer M Wolterink
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sanne G M van Velzen
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ivana Išgum
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
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37
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[Radiological imaging to assess individual cardiovascular risk]. Radiologe 2019; 59:35-42. [PMID: 30552484 DOI: 10.1007/s00117-018-0480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CLINICAL/METHODICAL ISSUE Radiologic imaging for the assessment of individual cardiovascular risk. STANDARD RADIOLOGICAL METHODS The correct estimation of the individual cardiovascular risk is prerequisite for the prevention of cardiovascular diseases. Here, extensive evidence is available for coronary calcium scans as well as coronary CT angiography (CTA). METHODICAL INNOVATIONS Summary of the available evidence for the use of calcium score and coronary CTA. Illustration of the significance of both tests in current guidelines. PERFORMANCE Both tests have high prognostic value, surpassing a risk-factor based assessment. In comparison with the calcium score, the CTA has higher incremental value. ACHIEVEMENTS Results from recent trials confirm an improvement of outcomes in symptomatic patients by performing a CTA compared with standard care. PRACTICAL RECOMMENDATIONS European and US guidelines recommend a calcium score for risk stratification of asymptomatic patients with a low to intermediate risk profile. For symptomatic patients with low to intermediate coronary artery disease pretest probability, a CTA is recommended.
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Halliday K, Maskell G. Managing the capacity gap in radiology reporting. Br J Hosp Med (Lond) 2019; 80:244-245. [DOI: 10.12968/hmed.2019.80.5.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Katharine Halliday
- Consultant Paediatric Radiologist, Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham
| | - Giles Maskell
- Consultant Radiologist, Department of Radiology, Royal Cornwall Hospitals NHS Trust, Truro TR1 3LJ
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Affiliation(s)
| | - Edward D Nicol
- Departments of Cardiology and Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Wu Z, He Y, Li W, Cheng S. Computed tomography coronary angiography vs. standard diagnostic procedure for the diagnosis of angina due to coronary heart disease: A cross-sectional study. Exp Ther Med 2019; 17:2485-2494. [PMID: 30906436 PMCID: PMC6425132 DOI: 10.3892/etm.2019.7229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022] Open
Abstract
Patients with episodes of angina are likely to experience future cardiac events and benefit from a revascularization procedure. Conventional invasive coronary angiography is a well-established and reliable method for the detection of angina, but it has a risk of complications and false-negative diagnosis. The objective of the present study was to assess the utility of computed tomography coronary angiography (CTCA) in the diagnosis of angina due to coronary heart disease. A total of 2,426 patients with chest pain referred to the rapid access chest pain clinic of Beijing Anzhen Hospital, Capital Medical University (Beijing, P.R. China) between 18 January 2016 and 1 December 2017 were included in the present cross-sectional study. All patients were subjected to evaluation of symptoms, blood tests, 12-lead electrocardiogram (ECG), exercise ECG, coronary artery calcium scoring and CTCA. The cost of the diagnosis of angina was determined for each individual method. In total, 776 (32%) and 1,420 (58%) of patients were identified to be abnormal on clinical assessment and CTCA, respectively. Exercise ECG results were not correlated with the interpretation of CTCA (r=0.8511). The working area of the angina due to coronary heart disease detected at one time by the different diagnostic procedures was in the order of ECG <clinical assessment <exercise ECG <coronary artery calcium scoring <CTCA. The cost of the 'standard diagnostic procedure (clinical assessments, ECG, exercise ECG)' was 15,452±806 ¥/patient and that of CTCA was 12,546±612 ¥/patient. CTCA had a higher sensitivity for the diagnosis of angina due to coronary heart disease and the cost was lower than that of the 'standard diagnostic procedure' (level of evidence: 3). The current study was registered at the Research Registry on 11th January 2016 (trial no. researchregistry4232).
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Affiliation(s)
- Zheng Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, P.R. China
| | - Yi He
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, P.R. China
| | - Wenzheng Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, P.R. China
| | - Shujuan Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, P.R. China
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Berry C, Corcoran D, Mangion K. Cardiovascular health technology assessment: recommendations to improve the quality of evidence. Open Heart 2019; 6:e000930. [PMID: 30997126 PMCID: PMC6443128 DOI: 10.1136/openhrt-2018-000930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/13/2018] [Accepted: 01/20/2019] [Indexed: 01/09/2023] Open
Abstract
The aim of this article is to review the role of Health Technology Assessment (HTA) organisations in appraising and recommending innovative cardiovascular technologies. We consider how bias impairs the quality of evidence from clinical trials involving cardiovascular healthcare technologies. Finally, we provide recommendations to HTA organisations to take account of bias when making guideline recommendations. Clinical research studies of medical devices, diagnostics and interventions in cardiovascular healthcare are susceptible to impairment through bias. While HTA organisations, such as the National Institute of Health and Care Excellence, may require reviewers to take account of bias, there are uncertainties as to how this is achieved, especially in cardiovascular technology trials. This becomes more relevant given that large trials are few in number; therefore, the quality of evidence from an individual trial may have a large bearing on guideline recommendations and clinical practice. HTA organisations should drive improvements in the design and rigour of randomised trials. The evolving landscape of cardiovascular healthcare technologies and related trials presents a challenge for HTA organisations and healthcare providers. The rapid turnover of evidence is externally relevant because the period from the trial publication to implementation of HTA guideline recommendations by healthcare providers may be prolonged, by which time new evidence may have emerged from subsequent trials. Implementation of a cardiovascular healthcare technology including be it a medical device, diagnostic or intervention may have profound implications for healthcare providers. These technologies may have high absolute costs and access may be influenced by socioeconomic and geographic factors.
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Affiliation(s)
- Colin Berry
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David Corcoran
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kenneth Mangion
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Masri A, Murthy VL. Clinical Risk Scores to Minimize Low Yield Coronary Artery Disease Testing. Circ Cardiovasc Imaging 2019; 12:e008626. [PMID: 30712365 DOI: 10.1161/circimaging.118.008626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ahmad Masri
- Division of Cardiovascular Medicine, Department of Medicine and the Heart and Vascular Institute, University of Pittsburgh (A.M.)
| | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine and Frankel Cardiovascular Center, University of Michigan, Ann Arbor (V.L.M.)
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Asher A, Singhal A, Thornton G, Wragg A, Davies C. FFR CT derived from computed tomography angiography: the experience in the UK. Expert Rev Cardiovasc Ther 2018; 16:919-929. [PMID: 30347174 DOI: 10.1080/14779072.2018.1538786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Non-invasive fractional flow reserve derived from CT coronary angiography (FFRCT) represents a novel technology to investigate coronary artery disease. The application of computational flow dynamics to anatomical data provides the clinician with a further functional assessment to inform decision-making in patients with coronary artery disease. In the UK FFRCT has received medical technology approval for use since February 2017. Areas covered: This article discusses the mathematical and physiological principles underpinning calculation of non-invasive fractional flow reserve (FFR), as well as discussing the differences between the commercially available technologies. Diagnostic accuracy, cost effectiveness and safety of non-invasive FFR from the early clinical trials is examined. Further to this the potential implications of the use of non-invasive FFR in clinical practice in the UK are discussed. Expert commentary: Non-invasive FFR represents a promising comprehensive imaging technology providing both anatomical and physiological data to accurately diagnose obstructive coronary artery disease. The technology has yet to prove to be cost effective in 'real world' cohorts before becoming integrated into everyday clinical practice and guidelines in the United Kingdom.
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Affiliation(s)
- Alex Asher
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - Arvind Singhal
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - George Thornton
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - Andrew Wragg
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
| | - Ceri Davies
- a The Royal London Hospital and St Bartholomew's Hospital, London, Barts Health NHS Trust , London , UK
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Oikonomou EK, Marwan M, Desai MY, Mancio J, Alashi A, Hutt Centeno E, Thomas S, Herdman L, Kotanidis CP, Thomas KE, Griffin BP, Flamm SD, Antonopoulos AS, Shirodaria C, Sabharwal N, Deanfield J, Neubauer S, Hopewell JC, Channon KM, Achenbach S, Antoniades C. Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data. Lancet 2018; 392:929-939. [PMID: 30170852 PMCID: PMC6137540 DOI: 10.1016/s0140-6736(18)31114-0] [Citation(s) in RCA: 552] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/29/2018] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Coronary artery inflammation inhibits adipogenesis in adjacent perivascular fat. A novel imaging biomarker-the perivascular fat attenuation index (FAI)-captures coronary inflammation by mapping spatial changes of perivascular fat attenuation on coronary computed tomography angiography (CTA). However, the ability of the perivascular FAI to predict clinical outcomes is unknown. METHODS In the Cardiovascular RISk Prediction using Computed Tomography (CRISP-CT) study, we did a post-hoc analysis of outcome data gathered prospectively from two independent cohorts of consecutive patients undergoing coronary CTA in Erlangen, Germany (derivation cohort) and Cleveland, OH, USA (validation cohort). Perivascular fat attenuation mapping was done around the three major coronary arteries-the proximal right coronary artery, the left anterior descending artery, and the left circumflex artery. We assessed the prognostic value of perivascular fat attenuation mapping for all-cause and cardiac mortality in Cox regression models, adjusted for age, sex, cardiovascular risk factors, tube voltage, modified Duke coronary artery disease index, and number of coronary CTA-derived high-risk plaque features. FINDINGS Between 2005 and 2009, 1872 participants in the derivation cohort underwent coronary CTA (median age 62 years [range 17-89]). Between 2008 and 2016, 2040 patients in the validation cohort had coronary CTA (median age 53 years [range 19-87]). Median follow-up was 72 months (range 51-109) in the derivation cohort and 54 months (range 4-105) in the validation cohort. In both cohorts, high perivascular FAI values around the proximal right coronary artery and left anterior descending artery (but not around the left circumflex artery) were predictive of all-cause and cardiac mortality and correlated strongly with each other. Therefore, the perivascular FAI measured around the right coronary artery was used as a representative biomarker of global coronary inflammation (for prediction of cardiac mortality, hazard ratio [HR] 2·15, 95% CI 1·33-3·48; p=0·0017 in the derivation cohort, and 2·06, 1·50-2·83; p<0·0001 in the validation cohort). The optimum cutoff for the perivascular FAI, above which there is a steep increase in cardiac mortality, was ascertained as -70·1 Hounsfield units (HU) or higher in the derivation cohort (HR 9·04, 95% CI 3·35-24·40; p<0·0001 for cardiac mortality; 2·55, 1·65-3·92; p<0·0001 for all-cause mortality). This cutoff was confirmed in the validation cohort (HR 5·62, 95% CI 2·90-10·88; p<0·0001 for cardiac mortality; 3·69, 2·26-6·02; p<0·0001 for all-cause mortality). Perivascular FAI improved risk discrimination in both cohorts, leading to significant reclassification for all-cause and cardiac mortality. INTERPRETATION The perivascular FAI enhances cardiac risk prediction and restratification over and above current state-of-the-art assessment in coronary CTA by providing a quantitative measure of coronary inflammation. High perivascular FAI values (cutoff ≥-70·1 HU) are an indicator of increased cardiac mortality and, therefore, could guide early targeted primary prevention and intensive secondary prevention in patients. FUNDING British Heart Foundation, and the National Institute of Health Research Oxford Biomedical Research Centre.
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Affiliation(s)
- Evangelos K Oikonomou
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Mohamed Marwan
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Milind Y Desai
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Jennifer Mancio
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alaa Alashi
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | | | - Sheena Thomas
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Laura Herdman
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Christos P Kotanidis
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Katharine E Thomas
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Brian P Griffin
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Scott D Flamm
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH, USA
| | - Alexios S Antonopoulos
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Cheerag Shirodaria
- Cardiology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Caristo Diagnostics, Oxford, UK
| | - Nikant Sabharwal
- Cardiology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John Deanfield
- University College London Institute of Cardiovascular Science, London, UK
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Centre of Research Excellence, British Heart Foundation, Oxford, UK; Oxford Biomedical Research Centre, National Institute of Health Research, Oxford, UK
| | - Jemma C Hopewell
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Keith M Channon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Centre of Research Excellence, British Heart Foundation, Oxford, UK; Oxford Biomedical Research Centre, National Institute of Health Research, Oxford, UK
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Oxford Centre of Research Excellence, British Heart Foundation, Oxford, UK; Oxford Biomedical Research Centre, National Institute of Health Research, Oxford, UK.
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Cardiac CT: Global Use and Comparison of International Guidelines. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9464-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Otto CM. Heartbeat: Is it feasible to use computed tomographic coronary angiography for first-line diagnosis in chest pain patients? BRITISH HEART JOURNAL 2018; 104:872-874. [DOI: 10.1136/heartjnl-2018-313443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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