Modified Haller index is inversely correlated with true positive exercise stress echocardiographic results

Accuracy of noninvasive screening exercise tests for detecting coronary artery disease in symptomatic patients with mitral valve prolapse: a systematic review

BACKGROUND

Since the 1970s, only a few studies have evaluated the accuracy of noninvasive screening exercise tests for detecting coronary artery disease (CAD) in symptomatic individuals with mitral valve prolapse (MVP). The present systematic review has been designed to summarize the main findings of these studies and to assess the overall pooled estimates of sensivity and specificity of exercise ECG, exercise myocardial perfusion scintigraphy (MPS) and exercise stress echocardiography (ESE) in diagnosing CAD among MVP individuals.

METHODS

All studies examining the specificity and sensitivity of exercise ECG and/or exercise MPS and/or ESE in detecting obstructive CAD in symptomatic MVP patients, selected from PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

The full texts of 11 studies with 840 MVP individuals were analyzed. True obstructive CAD was documented in 11.1% of MVP individuals (range 0-31.2%). When used in MVP patients with suspected CAD, exercise ECG, exercise MPS and ESE showed a pooled specificity of 61.9% (range 25-91.7%), 82.3% (range 25-100%) and 89% (range 80.5-97.6%), respectively, and a pooled sensitivity of 80% (range 50-100%), 96.7% (range 90-100%) and 91% (range 82-100%), respectively. The pooled positive predictive value was 33.2% (range 23.1-44.8%) for exercise ECG, 100% for exercise MPS and 80.2% (range 75.8-84.6%) for ESE, whereas the pooled negative predictive value was 80% (range 50-100%) for exercise ECG, 97% for exercise MPS and 99% (range 97.6-100%) for ESE.

CONCLUSION

ESE appears to be the first-choice screening method for CAD detection in symptomatic MVP individuals. It allows true CAD in symptomatic MVP individuals with false-positive exercise ECG results to be ruled out, without ionizing radiation exposure.

Prevalence of Mitral Valve Prolapse Among Individuals with Pectus Excavatum: A Systematic Review and Meta-Analysis

Background: During the last decades, a small number of studies reported a wide range of variability in the estimated prevalence of mitral valve prolapse (MVP) among individuals with pectus excavatum (PE). The present systematic review and meta-analysis has been primarily designed to summarize the main findings of these studies and to estimate the overall prevalence of MVP among PE individuals. Methods: All imaging studies assessing the prevalence of MVP in PE individuals vs. healthy controls, selected from PubMed and EMBASE databases, were included. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment of Case-Control Studies. Events (presence of MVP) and nonevents (absence of MVP) in PE individuals and control groups were recorded. The main outcome was the measure of odds ratio (OR) for MVP presence pooled with 95% confidence intervals, using a fixed-effects model. Results: The full texts of eight studies with 303 PE patients (mean age 25.7 yrs) and 498 healthy controls (mean age 31 yrs) were analyzed. Three studies assessed MVP prevalence in children and early adolescents, whereas the remaining five studies examined PE adults. The prevalence of MVP in PE individuals and healthy controls was 40.6% and 12.8%, respectively. In the pooled sample, the OR for MVP presence was significantly higher in PE individuals compared to controls (OR = 5.80, 95%CI = 3.83-8.78, Z = 8.30, p < 0.001). Subgroup analysis revealed that MVP prevalence was approximately three-fold higher among PE children and early adolescents compared with PE adults. Overall, high consistency was observed in the pooled effect sizes, due to the low statistical heterogeneity among the included studies (I2 = 22.7%, p = 0.25). Egger's test for a regression intercept gave a p-value of 0.07, indicating no publication bias. The sensitivity analysis supported the robustness of the results. Conclusions: PE individuals are nearly six times more likely to have MVP than controls. MVP prevalence is three-fold higher in PE individuals during childhood and early adolescence, compared to PE adults. Given the strong association between MVP and PE, MVP should be suspected in all individuals with anterior chest wall deformity.

Echocardiographic Assessment of Mitral Valve Prolapse Prevalence before and after the Year 1999: A Systematic Review

Background: Over the last five decades, a fair number of echocardiographic studies have evaluated the prevalence of mitral valve prolapse (MVP) in various cohorts of individuals, including heterogeneous study populations. The present systematic review has been primarily designed to summarize the main findings of these studies and to estimate the overall MVP prevalence in the general community. Methods: All echocardiographic studies assessing the MVP prevalence in various cohorts of individuals, selected from PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The full texts of 21 studies with 1354 MVP individuals out of 63,723 participants were analyzed. The overall pooled prevalence of MVP was 4.9% (range of 0.6-21%). When dividing the studies in two groups according to the echocardiographic criteria used for MVP diagnosis (less specific old criteria or more specific new criteria, respectively), the estimated pooled prevalence of MVP was 7.8% (range of 2-21%) for the older studies (performed between 1976 and 1998) and 2.2% (range of 0.6-4.2%) for the more recent ones (conducted between 1999 and 2021). Potential selection bias, hospital- or referral-based series, and the use of less specific echocardiographic criteria for MVP diagnosis have been indicated as the main reasons for the higher MVP prevalence detected by the older studies. MVP was commonly associated with a narrow antero-posterior thoracic diameter, isolated ventricular premature beats and nonspecific ST-T-wave abnormalities on a resting electrocardiogram, mild-to-moderate mitral regurgitation (MR), the reduced probability of obstructive coronary artery disease, and a low frequency of serious complications, such as severe MR, infective endocarditis, heart failure, stroke, and atrial fibrillation. Conclusions: MVP has a low prevalence in the general population, regardless of age, gender, and ethnicity, and is associated with a good outcome.

Between Two Worlds: Investigating the Intersection of Human Expertise and Machine Learning in the Case of Coronary Artery Disease Diagnosis

Coronary artery disease (CAD) presents a significant global health burden, with early and accurate diagnostics crucial for effective management and treatment strategies. This study evaluates the efficacy of human evaluators compared to a Random Forest (RF) machine learning model in predicting CAD risk. It investigates the impact of incorporating human clinical judgments into the RF model's predictive capabilities. We recruited 606 patients from the Department of Nuclear Medicine at the University Hospital of Patras, Greece, from 16 February 2018 to 28 February 2022. Clinical data inputs included age, sex, comprehensive cardiovascular history (including prior myocardial infarction and revascularisation), CAD predisposing factors (such as hypertension, dyslipidemia, smoking, diabetes, and peripheral arteriopathy), baseline ECG abnormalities, and symptomatic descriptions ranging from asymptomatic states to angina-like symptoms and dyspnea on exertion. The diagnostic accuracies of human evaluators and the RF model (when trained with datasets inclusive of human judges' assessments) were comparable at 79% and 80.17%, respectively. However, the performance of the RF model notably declined to 73.76% when human clinical judgments were excluded from its training dataset. These results highlight a potential synergistic relationship between human expertise and advanced algorithmic predictions, suggesting a hybrid approach as a promising direction for enhancing CAD diagnostics.

The relationship between mitral valve prolapse and thoracic skeletal abnormalities in clinical practice: a systematic review

BACKGROUND

Literature data suggest high inter-study variability in mitral valve prolapse (MVP) prevalence among individuals with thoracic skeletal abnormalities (TSA). This systematic review aimed at estimating the overall prevalence of MVP in individuals with the most common TSA, including not only the oldest studies (before the year 2000) but also the most recent ones (after the year 2000).

METHODS

PubMed and EMBASE databases were systematically reviewed in November 2023. Studies assessing the relationship between MVP and TSA and estimating the MVP prevalence in pectus excavatum (PE), pectus carinatum (PC), scoliosis, straight back syndrome (SBS) and Marfan syndrome (MS) were included. There was no limitation on time periods.

RESULTS

Twenty-five studies with a total of 2800 patients (27.9 ± 13.9 years, 48.2% females) were analyzed. The highest prevalence of MVP was observed among MS patients (47.3%), while the lowest was detected in PC individuals (23%). Prevalence of MVP was similar among PE (30.8%), scoliosis (26.3%) and SBS (25.5%) patients. When dividing the studies on the basis of temporal period, the average MVP prevalence was approximately two-fold higher in all studies conducted before the year 2000 in comparison with the most recent ones, regardless of TSA type. This discrepancy might be primarily ascribed to relevant differences in the echocardiographic criteria employed for MVP diagnosis before (less specific) and after (more specific) the year 2000, respectively.

CONCLUSIONS

The estimated MVP prevalence in TSA individuals is significantly higher than that observed in the general population. Individuals with TSA should be screened for MVP presence on transthoracic echocardiography.