Prognostic value of non-invasive stress testing for coronary artery disease in obese patients

Sex differences in guideline adherence for coronary angiography in patients with suspected chronic coronary syndrome in Germany: insights from the ENLIGHT-KHK trial

BACKGROUND

For the management of acute coronary syndrome, literature shows lower healthcare providers' guideline adherence for women than for men. Since less is known about the management of chronic coronary syndrome (CCS), this study investigated patient-related sex differences in providers' guideline adherence for invasive coronary angiography (CA) performed in patients with suspected CCS.

METHODS

Using data from the German ENLIGHT-KHK trial, patients with suspected CCS who underwent a CA were analysed. To assess the association between patient sex and physicians' adherence to the German National Disease Management Guideline "Chronic coronary artery disease" of 2019, binary logistic regression models were developed. Covariates included age, symptoms, risk factors, comorbidities, and non-invasive testing and its results. To examine sex differences in predictors of guideline adherence, models were run separately for women and men.

RESULTS

Two hundred seventy-three women and three hundred eighty-six men were included (aged 67 ± 10 years). Physicians' guideline adherence for CA was lower for women than for men (19.4% vs. 30.1%, p = 0.002). CAs were less likely to be guideline-adherent for women with suspected CCS than men (OR 0.4, p < 0.05). Guideline adherence predictors differed between women and men. For example, men's predictors included non-invasive testing and its results, age, typical angina and smoking; of these, only a positive non-invasive test result had an impact for women.

CONCLUSION

Our results indicate a less guideline-adherent diagnostic workup of CA for women with suspected CCS than men. This might reflect a limited awareness of CCS in women and insufficiently sex-specific guideline recommendations.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00015638, Registered February 19, 2019; Universal Trial Number (UTN): U1111-1227-8055.

Effect of Body Mass Index on Effectiveness of CT versus Invasive Coronary Angiography in Stable Chest Pain: The DISCHARGE Trial

Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%-60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article.

Challenges in Cardiovascular Evaluation and Management of Obese Patients: JACC State-of-the-Art Review

Many unique clinical challenges accompany the diagnosis and treatment of cardiovascular disease (CVD) in people living with overweight/obesity. Similarly, physicians encounter numerous complicating factors when managing obesity among people with CVD. Diagnostic accuracy in CVD medicine can be hampered by the presence of obesity, and pharmacological treatments or cardiac procedures require careful adjustment to optimize efficacy. The obesity paradox concept remains a source of confusion within the clinical community that may cause important risk factors to go unaddressed, and body mass index is a misleading measure that cannot account for body composition (eg, lean mass). Lifestyle modifications that support weight loss require long-term commitment, but cardiac rehabilitation programs represent a potential opportunity for structured interventions, and bariatric surgery may reduce CVD risk factors in obesity and CVD. This review examines the key issues and considerations for physicians involved in the management of concurrent obesity and CVD.

CMR stress testing in a patient with morbid obesity (BMI 58 kg/m2) and suspected coronary artery disease

Background

Severe obesity is asscociated with an increased risk of coronary artery disease (CAD) but non-invasive cardiac imaging modalities have important technical limits.

Case presentation

We report a case of a 58-year old patient with suspected CAD and severely elevated BMI of 58 kg/m².

Conclusions

Stress-CMR was able to non-invasively stratify risk with good imaging quality despite the body dimensions of the patient.