Diagnostic accuracy and reclassification potential of the acoustic CADScor algorithm in intermediate risk patients with suspected coronary artery disease

Background

Validation studies of the 2019 European Society of Cardiology pre-test probability model (ESC-PTP) for coronary artery disease (CAD) report that 35–40% of patients have intermediate pre-test risk (ESC-PTP 5-<15%). A clear strategy for deferral or referral in this group has not been established. Stratification tools with a high negative predictive value (NPV) are especially wanted to improve pre-test risk estimates.

Acoustic detections of coronary stenosis are a new technology which could potentially be useful to supplement PTP stratification. One of the devices, the CADScor®System, has been shown to down-classify >40% of patients to low risk without increasing CAD prevalence. However, the clinical utility of using the CADScor algorithm (version (V)3.1) has not be validated.

Purpose

1) To validate the diagnostic performance of the CADScor®System (V3.1), and 2) to study the reclassification potential of a clinical likelihood strategy by ESC-PTP estimation supplemented by a CAD-score.

Methods

In total, 1732 patients without known CAD but with symptoms suggestive hereof underwent coronary CTA as a first-line diagnostic test. Based on an interview prior to coronary CTA, the ESC-PTP model was applied and sound recordings were performed using the acoustic CADScor® System. Patients with a suspected >50% diameter stenosis in any coronary segment at coronary CTA were referred to investigation with Invasive angiography (ICA) with measurement of Fractional flow reserve (FFR).

The ESC-PTP risk estimation was divided according to the recommended cut-offs of <5%, 5-<15% and >15% PTP of obstructive CAD. Haemodynamically obstructive CAD was defined as: (1) FFR value <0.80, (2) luminal diameter stenosis reduction >90%, or (3) luminal diameter stenosis reduction ≥50% if FFR was indicated but not performed. A predefined cut-off value of 20 was used for CAD-score values to rule-out CAD.

Results

A suspected stenosis was found in 439 patients (26%) after coronary CTA. The follow up with ICA with FFR showed significant stenoses in 198 patients (12%).

In the entire cohort using the ≤20 CAD-score cutoff for CAD rule-out, sensitivity was 85.3% (95% CI 79.5–89.9%), specificity was 40.3% (95% CI 37.8–42.9%), the PPV was 5.9% (95% CI 13.8–18.3%)), and the NPV was 95.4% (95% CI 93.4–96.9%). Hence, the disease prevalence of obstructive CAD was 4.6% in the ruled-out patients.

Applying the ≤20 CAD-score cutoff for CAD rule-out in intermediate risk patients (ESC-PTP 5-<15%) a total of 316 patients (48%) were down-classified to low risk with an obstructive CAD prevalence of 3.5%.

Conclusion

Having high NPV, the CADscor holds excellent rule-out power. Interestingly, the CADscor has reclassification properties in intermediate CAD risk patients where almost 50% can be deferred form further testing without increasing obstructive CAD risk. Thus, the CADscor can supplement clinical assessment to guide decisions on the need for further testing.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was supported by the Health Research Fund of Central Denmark Region, Aarhus University Research foundation and by an institutional research grant from Acarix A/S, Denmark. Patient flowReclassification potential

P2713A genetic risk score improves discrimination of hemodynamically obstructive coronary artery disease (CAD) beyond the CAD Consortium scores in patients at low-to-intermediate risk of CAD

Background

Genetic risk scores (GRSs), based on variants identified in genome-wide association studies (GWAS), have been shown to predict risk of coronary artery disease (CAD). However, the clinical potential remains unknown.

Purpose

To investigate whether a GRS improves discrimination of hemodynamically obstructive CAD beyond the CAD Consortium scores and coronary artery calcium score (CACS) in patients referred for coronary computed tomography angiography (CTA).

Methods

We consecutively included and genotyped 1645 patients undergoing CACS scoring and coronary CTA on a suspicion of CAD. Using LDPred, a recently validated GRS was calculated as the weighted sum of the number of CAD risk variants identified from the CARDIoGRAMplusC4D GWAS meta-analysis. Patients with a ≥50% stenosis on CTA further underwent invasive coronary angiography (ICA) with fractional flow reserve (FFR). Hemodynamically obstructive CAD was defined as a visual ICA stenosis >90%, FFR <0.80, or a quantitative coronary analysis stenosis >50% if FFR was not feasible. Discrimination was evaluated by receiver-operating characteristics.

Results

Median age was 57 (interquartile range 50–64) years and 799 (49%) were males. Hemodynamically obstructive CAD was present in 14 (4%) with a low GRS (<20th percentile), 91 (9%) with an intermediate GRS (20th–80th percentile) and 53 (16%) with a high GRS (>80th percentile) (p<0.0001). Adding the GRS improved the area under the receiver-operating curve (AUC) on top of the CAD Consortium basic score (from 0.67 to 0.72, p=0.0052), and the CAD Consortium clinical score (0.70 to 0.74, p=0.0084), but not on top of the CAD Consortium clinical score + CACS (0.85 to 0.86, p=0.30). Improvement in discrimination on top of the CAD Consortium scores was predominantly driven by females ≤57 years (CAD Consortium basic score ± GRS: 0.60 to 0.78, p=0.0004; CAD Consortium clinical score ± GRS: 0.63 to 0.78, p=0.0007). The GRS did not improve discrimination in any subgroups including CACS (CAD Consortium clinical score + CACS ± GRS: all p-values >0.05).

Conclusion

A GRS improves discrimination of hemodynamically obstructive CAD beyond CAD consortium scores, particularly in young women. However, the additive discriminative value is attenuated in models including CACS.

Coronary artery disease risk reclassification by a new acoustic-based score

To determine the potential of a non-invasive acoustic device (CADScor®System) to reclassify patients with intermediate pre-test probability (PTP) and clinically suspected stable coronary artery disease (CAD) into a low probability group thereby ruling out significant CAD. Audio recordings and clinical data from three studies were collected in a single database. In all studies, patients with a coronary CT angiography indicating CAD were referred to coronary angiography. Audio recordings of heart sounds were processed to construct a CAD-score. PTP was calculated using the updated Diamond-Forrester score and patients were classified according to the current ESC guidelines for stable CAD: low < 15%, intermediate 15–85% and high > 85% PTP. Intermediate PTP patients were re-classified to low probability if the CAD-score was ≤ 20. Of 2245 patients, 212 (9.4%) had significant CAD confirmed by coronary angiography ( ≥ 50% diameter stenosis). The average CAD-score was higher in patients with significant CAD (38.4 ± 13.9) compared to the remaining patients (25.1 ± 13.8; p < 0.001). The reclassification increased the proportion of low PTP patients from 13.6% to 41.8%, reducing the proportion of intermediate PTP patients from 83.4% to 55.2%. Before reclassification 7 (3.1%) low PTP patients had CAD, whereas post-reclassification this number increased to 28 (4.0%) (p = 0.52). The net reclassification index was 0.209. Utilization of a low-cost acoustic device in patients with intermediate PTP could potentially reduce the number of patients referred for further testing, without a significant increase in the false negative rate, and thus improve the cost-effectiveness for patients with suspected stable CAD.

Influence of Cardiac CT based disease severity and clinical symptoms on the diagnostic performance of myocardial perfusion

We aimed to identify factors influencing the sensitivity of perfusion imaging after an initial positive coronary computed tomography angiography (CCTA) using invasive coronary angiography (ICA) with conditional fractional flow reserve (FFR) as reference. Secondly we aimed to identify factors associated with revascularisation and to evaluate treatment outcome after ICA. We analysed 292 consecutive patients with suspected significant coronary artery disease (CAD) at CCTA, who underwent perfusion imaging with either cardiac magnetic resonance (CMR) or myocardial perfusion scintigraphy (MPS) followed by ICA with conditional FFR. Stratified analysis and uni- and multiple logistic regression analyses were performed to identify predictors of diagnostic agreement between perfusion scans and ICA and predictors of revascularisation. Myocardial ischemia evaluated with perfusion scans was present in 65/292 (22%) while 117/292 (40%) had obstructive CAD evaluated by ICA. Revascularisation rate was 90/292 (31%). The overall sensitivity for perfusion scans was 39% (30-48), specificity 89% (83-93), PPV 69% (57-80) and NPV 68% (62-74). Stratified analysis showed higher sensitivities in patients with multi-vessel disease at CCTA 49% (37-60) and typical chest pain 50% (37-60). Predictors of revascularisation were multi-vessel disease by CCTA (OR 3.51 [1.91-6.48]) and a positive perfusion scan (OR 4.69 [2.49-8.83]). The sensitivity for perfusion scans after CCTA was highest in patients with typical angina and multiple lesions at CCTA and predicted diagnostic agreement between perfusion scans and ICA. Abnormal perfusion and multi vessel disease at CCTA predicted revascularisation.

Late coronary stent thrombosis

Coronary stent thromboses are characterized as early, if they occur within one month of the index PCI. Late stent thromboses (LST) have an occurrence after one month. Both early and late stent thromboses are a major concern in PCI, because of their clinical presentation as acute myocardial infarction and sudden cardiac death. Early stent thromboses are seen following implantation with bare metal (BMS) and drug eluting (DES) stents. Late occurring stent thromboses (LST) are rare but usually severe events and primarily seen after DES implantation. A number of pathogenetic mechanisms seem to be operating and there will probably be major differences between different types DES and the risk of LST. While early stent thrombosis is primarily related to stent implantation techniques, lesion characteristics and the effect of double platelet therapy, there is emerging evidence that very late stent thrombosis, occurring more than one year after the implantation may be caused by local tissue reaction to the polymers of sirolimus and paclitaxel eluting stents. It is likely that the use of new generations DES with tissue friendly polymers or bioabsorbable polymers will reduce the risk of late stent thrombosis.

Intra- and inter-investigator variation in the analysis of pressure-flow studies in men with lower urinary tract symptoms

The objective of this study was to assess the intra- and inter-investigator variation in the analysis of pressure-flow studies that were performed in men with lower urinary tract symptoms. Two hospitals were involved in this study. In each hospital 100 PFS were selected. Photocopies of printouts of all PFS were analyzed manually by six experienced investigators, including determination of P(detQmax) and Q(max). Afterward, all 200 PFS were analyzed again in a different order. For each P(detQmax) and accompanying Q(max) the AG-number was calculated. With these AG numbers, the intra-investigator SD, the inter-investigator SD and the intra- and inter-investigator SD combined were calculated. The intra- and inter-investigator SD combined was 10.7. This implies that if one investigator analyzes a PFS once and determines an AG number of 40, another investigator may determine an AG number between 40 +/- 2. 77*10.7 = 10-70, using a 95% confidence interval. The inter-investigator SD was 10.0 and the intra-investigator SD was 3.7. The reproducibility of the manual analysis of urodynamic studies is moderate owing to a considerable intra- and inter- investigator variation. This is mostly caused by the substantial intra-investigator variation.

Interstitial cystitis. Ultrastructural observations on detrusor smooth muscle cells

Ultrastructural investigation of detrusor muscle cells in biopsies from 13 patients (8 interstitial cystitis (IC) and 5 controls) was performed. In all IC-patients and in one control a varying number of smooth muscle cells revealed a characteristic oak leaf pattern with protrusions of the sarcolemma. The alterations may express degeneration of smooth muscle cells. Although most probably non-specific yet highly characteristic, the ultrastructural detrusor changes may be important in diagnosing IC.

Activation of calcium-dependent potassium channels in mouse [correction of rat] brain neurons by neurotrophin-3 and nerve growth factor

The neurotrophins are signaling factors that are essential for survival and differentiation of distinct neuronal populations during the development and regeneration of the nervous system. The long-term effects of neurotrophins have been studied in detail, but little is known about their acute effects on neuronal activity. Here we use permeabilized whole-cell patch clamp to demonstrate that neurotrophin-3 (NT-3) and nerve growth factor activate calcium-dependent, paxilline-sensitive potassium channels (BK channels) in cortical neurons. Application of NT-3 or nerve growth factor produced a rapid and gradual rise in BK current that was sustained for 30-50 min; brain-derived neurotrophic factor, ciliary neurotrophic factor, and insulin-like growth factor-1 had no significant effect. The response to NT-3 was blocked by inhibitors of protein kinases, phospholipase C, and serine/threonine protein phosphatase 1 and 2a. Omission of Ca2+ from the extracellular medium prevented the NT-3 effect. Our results indicate that NT-3 stimulates BK channel activity in cortical neurons through a signaling pathway that involves Trk tyrosine kinase, phospholipase C, and protein dephosphorylation and is calcium-dependent. Activation of BK channels may be a major mechanism by which neurotrophins acutely regulate neuronal activity.

Fixation of human detrusor smooth muscle cells: role of osmolarity and magnesium ions on the ultrastructural morphology

Magnesium ions added to fixatives for processing to Transmission Electron Microscopy (TEM) have been claimed to cause relaxation of detrusor smooth muscle cells [1]. This should facilitate the morphologic evaluation of the tissue. However, magnesium ions are osmotically active and their addition may cause the fixative to become hypertonic to the tissue. To ascertain whether the presence of magnesium ions causes significant changes compared to those found where the osmolarity is raised without the presence of magnesium, human detrusor specimens were fixed in glutaraldehyde to which increasing amounts of MgCl2 or NaCl were added in different concentrations. With the addition of increasing amounts of MgCl2 and NaCl, the osmolarity of the fixative increased, causing significant changes in the morphology and morphometry of the tissue. The intercellular distances increased, the cells shrank and the shape of the cells changed from smooth and rounded to spiky and angulated. With regard to its muscle-relaxing effect, it was not possible to distinguish the specimens fixed in magnesium-containing fixatives from those without. In this study it was not possible to prove any relaxing effect of magnesium ions added to the fixative. On the contrary the magnesium ions caused an increase in the osmolarity, with significant changes in both the morphometry and the morphology of the human detrusor smooth muscle cells.

A new technique for detrusor biopsy and its applicability in the ultrastructural study and diagnosis of voiding dysfunction

OBJECTIVE

To determine the clinical applicability of ultrasound-guided detrusor biopsy from the anterior bladder wall and to assess whether it is as representative and as sufficient for determining detrusor ultrastructure as the traditional transurethral biopsy from the lateral bladder wall.

MATERIALS AND METHODS

The detrusor structure in 22 biopsies. 11 obtained transabdominally and 11 transurethrally from 11 patients, was evaluated without knowledge of the biopsy method by light and electron microscopy, including morphometric analysis. In addition, several specimens from each of three bladders were evaluated, also 'blindly', for ultrastructural diagnosis of the detrusor in an independent current study of voiding dysfunction in geriatric patients.

RESULTS

There were no differences in intercellular distances and cell: nucleus ratios between transabdominal and transurethral biopsies in eight of the 11 patients. Furthermore, ultrasound-guided transabdominal biopsies were as representative of the detrusor as were transurethral biopsies.

CONCLUSION

The transabdominal approach is recommended as an easy, relatively inexpensive and efficient method of obtaining biopsies of the detrusor for study of its structure in voiding dysfunction. On the other hand, the observations and diagnoses made by 'blind' qualitative study of several specimens from the same bladder were identical. This, together with the similarity of detrusor structure in the transabdominal and transurethral biopsies, strongly supports the idea that such structure is relatively uniform throughout the entire bladder wall.

The symptomatic outcome of transurethral prostatectomy evaluated with the DAN-PSS-1 score system

We assessed the symptomatic outcome of transurethral prostatectomy with the newly developed self-administered questionnaire, Danish Prostate Symptom Score (DAN-PSS-1), in men suffering from uncomplicated benign prostatic hyperplasia (BPH). The questionnaire was filled in adequately by 53 men, median age 69 (range 52-82), preoperatively and 2, 4 and 6 months after transurethral prostatectomy (TUR-P). The DAN-PSS-1 symptom score showed a high degree of sensitivity as the preoperative total score was median 20 (quartiles 14-36) and decreased to 4, 0 and 1 (quartiles from 0-4) at the 2, 4, and 6-month control respectively. The symptoms related to voiding were relieved totally after 2 months while symptoms related to storage were first relieved completely at 4-month control. Bother from symptoms was relieved after 2 months, although some symptoms still remained. The questionnaire was internally consistent with a reliability coefficient, Cronbach's alpha (alphaCr), of 0.73. We conclude that the DAN-PSS-1 questionnaire is an efficient tool among others in the indication and evaluation of treatment of uncomplicated BPH.

Modulation of the Ca(2+)-dependent K+ channel, hslo, by the substituted diphenylurea NS 1608, paxilline and internal Ca2+

The high-conductance Ca(2+)-activated K channel (BK channel) is not only regulated by a number of physiological stimuli, but it is also sensitive to pharmacological modulation. We have stably expressed the alpha-subunit of the human BK channel, hslo, in HEK 293 cells and studied by patch-clamp technique how its gating is modulated by the channel activator NS 1608, by the selective channel blocker paxilline, as well as by changes in [Ca2+]i and Vm. The cells expressed 200-800 hslo channels per patch. The channel activity was determined by tail current analysis, and the activation curves were fitted to single Boltzmann functions, from which a gating charge for the hslo channel of 1.2 elementary charges was deduced. The hslo channel was very sensitive to changes in [Ca2+]i within the physiological range, whereas Ca(2+)-independent openings were seen at Ca2+ concentrations of 15 nM or below. NS 1608 shifted the hslo channel activation curve towards negative membrane potentials with an EC50 of 2.1 microM and a maximal shift of -74 mV. The channels activated by NS 1608 were sensitive to block by paxilline, but the two molecules apparently did not interact within the same site, since paxilline reduced the size of the tail current at all voltages, whereas NS 1608 shifted the activation curve along the voltage axis. Further, the effect of paxilline was Ca(2+)-sensitive, whereas NS 1608 elicited identical effects in the presence of either < 0.5 nM or 500 nM [Ca2+]i. NS 1608 hyperpolarized the cells by -50 to -70 mV, and paxilline depolarized them towards 0 mV. In addition to the effects on the steady state current NS 1608 also significantly influenced the non-stationary channel kinetics. In the presence of NS 1608 the time constants for deactivation of tail currents were more than tripled at all potentials. We have shown, that NS 1608 modulates steady-state BK currents and channel gating kinetics through a Ca(2+)-independent interaction with the alpha-subunit of the channel.

Detrusor in ageing and obstruction

It is disputed whether fibrosis of the detrusor is a consequence of obstruction or ageing. In the present study, bladder wall morphology was analyzed semiquantitatively in biopsies from "normal" young persons, infravesically obstructed and non-obstructed elderly persons. Fibrosis occurring around and inside muscle fascicles was demonstrated to the same degree with obstruction as well as ageing. Our results give rise to the question whether "prostatism" is related to obstruction per se or to ageing or both.

Gene expression and secretion of insulin-like growth factor-II and insulin-like growth factor binding protein-2 from cultured sheep choroid plexus epithelial cells

The gene expression of insulin-like growth factor II (IGF-II) and insulin-like growth factor binding protein-2 (IGFBP-2) has previously been demonstrated in rat and human choroid plexus by in situ hybridization analysis. In the present study we have characterized IGF-II and IGFBP-2 transcripts and proteins in primary cultures of epithelial cells from lateral choroid plexus of sheep brain. Northern blot analysis of total RNA showed one major IGF-II mRNA of 4.8 kb and four minor IGF-II transcripts of 1.5, 2.0, 3.0 and 6.0 kb as well as one IGFBP-2 transcript of 1.7 kb. Radioreceptor assay of conditioned medium from the cultured choroid plexus epithelial cells showed inhibition of [125I]IGF-I and [125I]IGF-II binding to mouse NIH 3T3 fibroblasts, the displacement curves being identical to that of unlabelled IGF-II. The conditioned medium was fractionated by gel filtration on a Bio-Gel P-60 column, and analysis by IGF-II radioreceptor assay showed two peaks of IGF-II-binding inhibitory activity of M(r) 7.5-10 and 25 kDa, suggesting the presence of both IGF-II, and an IGFBP. Western immunoblot analysis of conditioned medium with antibodies toward IGF-II and IGFBP-2 demonstrated proteins with M(r) 6 kDa and 32 kDa, respectively. Protein binding assays of the conditioned medium with [125I]IGF-I or [125]IGF-II demonstrated that the IGFBP present in the conditioned medium preferentially binds IGF-II. In conclusion, cultured sheep choroid plexus epithelial cells synthesize and secrete IGF-II and IGFBP-2, suggesting that the choroid plexus epithelium is the main source of these polypeptides in the cerebrospinal fluid.

[Is the clinical diagnosis of acute appendicitis good enough?]

In order to estimate the specificity of the clinical diagnosis of acute appendicitis, case records of 148 patients, who underwent appendectomy or who were diagnosed as having periappendicular abscess during one year at a regional hospital in Denmark were analyzed. Operations without finding acute appendicitis occurred in 25.4 per cent of the patients. The group of women in the fertile age (12-50 years) was prone to unnecessary surgery (51.9 per cent in this group had a normal appendix). In children, men and non-fertile women only a few patients had unnecessary surgery. Belated diagnoses (perforation and/or abscess) were found truly in 10.7 per cent of the cases, and, with a significant higher incidence, in elderly patients (age greater than 50 years). The possibilities of diminishing the incidence of unnecessary surgery and belated diagnoses are discussed.