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Curzen N, Nicholas Z, Stuart B, Wilding S, Hill K, Shambrook J, Eminton Z, Ball D, Barrett C, Johnson L, Nuttall J, Fox K, Connolly D, O'Kane P, Hobson A, Chauhan A, Uren N, Mccann GP, Berry C, Carter J, Roobottom C, Mamas M, Rajani R, Ford I, Douglas P, Hlatky MA. Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial. Eur Heart J 2021; 42:3844-3852. [PMID: 34269376 PMCID: PMC8648068 DOI: 10.1093/eurheartj/ehab444] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/10/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Aims Fractional flow reserve (FFRCT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFRCT would improve economic and clinical outcomes compared with standard care. Methods and results Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFRCT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFRCT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01). Conclusion A strategy of CTCA with selective FFRCT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.
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Affiliation(s)
- N Curzen
- Faculty of Medicine, University of Southampton.,Coronary Research Group, University Hospital Southampton
| | - Z Nicholas
- Coronary Research Group, University Hospital Southampton
| | - B Stuart
- Clinical Trials Unit, University of Southampton
| | - S Wilding
- Clinical Trials Unit, University of Southampton
| | - K Hill
- Clinical Trials Unit, University of Southampton
| | - J Shambrook
- Cardiothoracic Radiology, University Hospital Southampton
| | - Z Eminton
- Clinical Trials Unit, University of Southampton
| | - D Ball
- Clinical Trials Unit, University of Southampton
| | - C Barrett
- Clinical Trials Unit, University of Southampton
| | - L Johnson
- Clinical Trials Unit, University of Southampton
| | - J Nuttall
- Clinical Trials Unit, University of Southampton
| | - K Fox
- Imperial College, London, UK
| | | | - P O'Kane
- Dorset Heart Centre, University Hospitals Dorset, Bournemouth
| | - A Hobson
- Queen Alexandra Hospital, Portsmouth
| | | | - N Uren
- Royal Infirmary, Edinburgh
| | - G P Mccann
- Department of Cardiovascular Sciences, University of Leicester & NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - C Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow
| | - J Carter
- University Hospital of North Tees, Stockton on Tees
| | | | - M Mamas
- Royal Stoke University Hospital, Stoke-on-Trent
| | - R Rajani
- Guy's & St Thomas' Hospital, London
| | - I Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow
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Zheng A, Kira M, Adam RD, Papageorgiou P, Shambrook J, Abbas A, Vedwan K, Long J, Walkden M, Harden S, Peebles C, Flett AS. Characteristics and long-term outcomes of patients with reduced ejection fraction referred for adenosine stress perfusion cardiac magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Adenosine stress perfusion has been shown to be of minimal incremental benefit in distinguishing between ischaemic and non-ischaemic aetiology of severe left ventricular systolic dysfunction (LVSD) over and above that obtained from Cardiac Magnetic Resonance (CMR) with Late Gadolinium Enhancement (LGE). Stress CMR has, however, been shown to be effective in risk-stratifying LVSD patients, with ischaemia being an independent predictor of cardiovascular death or myocardial infarction (MI) and associated with higher rates of further intervention.
Purpose
Evaluate real world data from a single tertiary UK cardiac MRI centre to determine the characteristics and long-term clinical outcomes of patients with LVSD referred for stress CMR.
Methods
As part of an ongoing registry, all consenting patients with Ejection Fraction (EF) ≤40% and a completed adenosine stress perfusion CMR between January 2015 and December 2019 were included with prospective baseline data collection. All-cause mortality and cardiac hospitalisation, coronary angiography/revascularisation was determined from electronic hospital records. Outcomes were compared between the inducible ischaemia vs. no ischaemia groups, and LGE present vs. no LGE groups using chi square.
Results
The sample included 86 patients. The mean EF was 32 ± 6%. Median follow up was 3.8 years (range 41-2222 days). The indications for CMR were: 30 (35%) assess ischaemia, 35 (41%) assess LVSD aetiology and 21 (24%) LVSD assess viability.
Inducible ischemia was present in 30 (35%) patients and absent in 56 (65%). Patient characteristics and outcomes are shown in Table 1. Baseline characteristics were similar between the groups but there was a higher rate of hypertension and ischaemic heart disease in the ischaemia group. There was a non-significant difference in combined mortality and cardiac hospitalisation rates between the groups (40% vs. 27% p = 0.20).
LGE was present in 69 (80%) patients (28 with ischaemia; 41 without) and absent in 17 (20%, 2 with ischaemia, 15 without). The event rate was 23 (33%) vs. 4 (24%) between LGE vs. No LGE groups (p = 0.44). Of the 15 patients (17%) with no LGE or ischaemia; 2 died and 1 was hospitalised, there were no MI"s and no Percutaneous Coronary Intervention (PCI).
The lack of statistical difference in event rates between ischaemia and no ischaemia groups may be due to our relatively small sample size or could reflect the effectiveness of contemporary disease modifying treatment for Heart Failure with reduced EF.
Conclusion
This real-world data supports published findings that in patients with LVSD and no LGE on CMR, ischaemia is very uncommon and stress CMR is unlikely to increase diagnostic yield. Conversely, if stress CMR is performed and ischaemia is absent, incidence of subsequent angiography and revascularisation is very low, which is reassuring in clinical practice. In those patients without ischaemia and LGE, likelihood of MI is low.
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Affiliation(s)
- A Zheng
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Kira
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - RD Adam
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - P Papageorgiou
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - J Shambrook
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Abbas
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - K Vedwan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - J Long
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Walkden
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - S Harden
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - C Peebles
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - AS Flett
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Williams M, Weir-McCall J, Moss A, Schmitt M, Stirrup J, Holloway B, Gopalan D, Deshpande A, Morgan Hughes G, Agrawal B, Nicol E, Roditi G, Shambrook J, Bull R. Radiologist Opinions Regarding Reporting Incidental Coronary And Cardiac Calcification On Thoracic CT. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2020.06.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Briosa E Gala A, Dimarco A, Battison S, Shambrook J, Mahmoudi M, Abbas A. 77CT coronary angiography clinches the diagnosis in a patient with ST elevation following a suicide attempt. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez139.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Briosa E Gala
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Dimarco
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - S Battison
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - J Shambrook
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - M Mahmoudi
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Abbas
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Harries IB, Williams M, Weir-Mccall J, Vedwan K, Shambrook J, Roditi G, Nicol E, Moss A. 189CT TAVR assessment in the United Kingdom: insights from a national BSCI/BSCCT survey. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- I B Harries
- Bristol Heart Institute, Bristol, United Kingdom of Great Britain & Northern Ireland
| | - M Williams
- University of Edinburgh, Edinburgh Imaging Facility, Edinburgh, United Kingdom of Great Britain & Northern Ireland
| | - J Weir-Mccall
- University of Cambridge, School of Clinical Medicine, Biomedical Research Centre, Cambridge, United Kingdom of Great Britain & Northern Ireland
| | - K Vedwan
- University of Southampton, Department of Cardiothoracic Radiology, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - J Shambrook
- University of Southampton, Department of Cardiothoracic Radiology, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - G Roditi
- University of Glasgow, Institute of Clinical Sciences, Glasgow, United Kingdom of Great Britain & Northern Ireland
| | - E Nicol
- Royal Brompton Hospital, Departments of Cardiology and Radiology, London, United Kingdom of Great Britain & Northern Ireland
| | - A Moss
- University of Edinburgh, Edinburgh Imaging Facility, Edinburgh, United Kingdom of Great Britain & Northern Ireland
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Loganath K, Shambrook J, Moss A. 178How did that get there? coronary thrombosis with a bioprosthetic valve. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- K Loganath
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - J Shambrook
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
| | - A Moss
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain & Northern Ireland
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Shepherd B, Abbas A, McParland P, Fitzsimmons S, Shambrook J, Peebles C, Brown I, Harden S. MRI in adult patients with aortic coarctation: diagnosis and follow-up. Clin Radiol 2015; 70:433-45. [PMID: 25559379 DOI: 10.1016/j.crad.2014.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 11/21/2014] [Accepted: 12/03/2014] [Indexed: 12/20/2022]
Abstract
Aortic coarctation is a disease that usually presents in infancy; however, a proportion of patients present for the first time in adulthood. These lesions generally require repair with either surgery or interventional techniques. The success of these techniques means that increasing numbers of patients are presenting for follow-up imaging in adulthood, whether their coarctation was initially repaired in infancy or as adults. Thus, the adult presenting to the radiologist for assessment of possible coarctation or follow-up of coarctation repair is not an uncommon scenario. In this review, we present details of the MRI protocols and MRI findings in these patients so that a confident and accurate assessment can be made.
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Affiliation(s)
- B Shepherd
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - A Abbas
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - P McParland
- Department of Radiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - S Fitzsimmons
- Department of Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - J Shambrook
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - C Peebles
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - I Brown
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - S Harden
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Trust, Southampton, UK.
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Göbölös L, Miskolczi S, Pousios D, Tsang GM, Livesey SA, Barlow CW, Kaarne M, Shambrook J, Lipnevicius A, Ohri SK. Management options for aorto-oesophageal fistula: case histories and review of the literature. Perfusion 2013; 28:286-90. [PMID: 23401340 DOI: 10.1177/0267659113476329] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica. METHODS Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity. CONCLUSIONS Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.
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Affiliation(s)
- L Göbölös
- Department Cardiothoracic Surgery, Southampton General Hospital, Southampton University Hospital Trust, Southampton, UK.
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