Showing papers by "Leslee J. Shaw published in 2016"

CAD-RADS™: Coronary Artery Disease - Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology

Abstract: The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

Coronary Artery Disease - Reporting and Data System (CAD-RADS): An Expert Consensus Document of SCCT, ACR and NASCI: Endorsed by the ACC

Abstract: The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

A randomized, placebo-controlled trial of late Na current inhibition (ranolazine) in coronary microvascular dysfunction (CMD): impact on angina and myocardial perfusion reserve.

Abstract: Aims The mechanistic basis of the symptoms and signs of myocardial ischaemia in patients without obstructive coronary artery disease (CAD) and evidence of coronary microvascular dysfunction (CMD) is unclear. The aim of this study was to mechanistically test short-term late sodium current inhibition (ranolazine) in such subjects on angina, myocardial perfusion reserve index, and diastolic filling. Materials and results Randomized, double-blind, placebo-controlled, crossover, mechanistic trial in subjects with evidence of CMD [invasive coronary reactivity testing or non-invasive cardiac magnetic resonance imaging myocardial perfusion reserve index (MPRI)]. Short-term oral ranolazine 500–1000 mg twice daily for 2 weeks vs. placebo. Angina measured by Seattle Angina Questionnaire (SAQ) and SAQ-7 (co-primaries), diary angina (secondary), stress MPRI, diastolic filling, quality of life (QoL). Of 128 (96% women) subjects, no treatment differences in the outcomes were observed. Peak heart rate was lower during pharmacological stress during ranolazine (−3.55 b.p.m., P < 0.001). The change in SAQ-7 directly correlated with the change in MPRI (correlation 0.25, P = 0.005). The change in MPRI predicted the change in SAQ QoL, adjusted for body mass index (BMI), prior myocardial infarction, and site ( P = 0.0032). Low coronary flow reserve (CFR <2.5) subjects improved MPRI ( P < 0.0137), SAQ angina frequency ( P = 0.027), and SAQ-7 ( P = 0.041). Conclusions In this mechanistic trial among symptomatic subjects, no obstructive CAD, short-term late sodium current inhibition was not generally effective for SAQ angina. Angina and myocardial perfusion reserve changes were related, supporting the notion that strategies to improve ischaemia should be tested in these subjects. Trial registration clinicaltrials.gov Identifier: [NCT01342029][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01342029&atom=%2Fehj%2F37%2F19%2F1504.atom

Association of Coronary Stenosis and Plaque Morphology With Fractional Flow Reserve and Outcomes

Abstract: Importance Obstructive coronary lesions with reduced luminal dimensions may result in abnormal regional myocardial blood flow as assessed by stress-induced myocardial perfusion imaging or a significant fall in distal perfusion pressure with hyperemia-induced vasodilatation (fractional flow reserve [FFR] ≤0.80). An abnormal FFR has been demonstrated to identify high-risk lesions benefitting from percutaneous coronary intervention while safely allowing revascularization to be deferred in low-risk lesions, resulting in a decrease in the number of revascularization procedures as well as substantially reduced death and myocardial infarction. While FFR identifies hemodynamically significant lesions likely to produce ischemia-related symptoms, it remains less clear as to why it might predict the risk of acute coronary syndromes, which are usually due to plaque rupture and coronary thrombosis. Observations Although the atherosclerotic plaques with large necrotic cores (independent of the degree of luminal stenosis) are known to be associated with vulnerability to rupture and acute coronary syndromes, emerging evidence also suggests that they may induce greater rates of ischemia and reduced FFR compared with non–lipid-rich plaques also independent of the degree of luminal narrowing. It is proposed that the presence of large necrotic cores within the neointima may be associated with the inability of the vessel to dilate and may predispose to ischemia and abnormal FFR. Conclusions and Relevance Having a normal FFR requires unimpaired vasoregulatory ability and significant luminal stenosis. Therefore, FFR should identify lesions that are unlikely to possess large necrotic core, rendering them safe for treatment with medical therapy alone. Further studies are warranted to determine whether revascularization decisions in patients with stable coronary artery disease could be improved by assessment of both plaque composition and ischemia.

Long-Term Prognosis After Coronary Artery Calcium Scoring Among Low-Intermediate Risk Women and Men

Abstract: Cardiovascular screening of women using traditional risk factors has been challenging, with results often classifying a majority of women as lower risk than men. The aim of this report was to determine the long-term prognosis of asymptomatic women and men classified at low-intermediate risk undergoing screening with coronary artery calcium (CAC) scoring.A total of 2363 asymptomatic women and men with traditional risk factors aggregating into a low-intermediate Framingham risk score (6%-9.9%; 10-year predicted risk) underwent CAC scanning. Individuals were followed up for a median of 14.6 years. We estimated all-cause mortality using Cox proportional hazards models; hazard ratios with 95% confidence intervals were calculated. The area under the curve from a receiver operating characteristics curve analysis was calculated. There were 1072 women who were older (55.6 years) when compared with the 1291 men (46.7 years; P 10 had a higher mortality risk when compared with men.Our findings extend previous work that CAC effectively identifies high-risk women with a low-intermediate risk factor burden. These data require validation in external cohorts but lend credence to the use of CAC in women to improve risk detection algorithms that are currently based on traditional risk factors.

Cardiovascular Disease and 10-Year Mortality in Postmenopausal Women with Clinical Features of Polycystic Ovary Syndrome.

Abstract: Background: Women with polycystic ovary syndrome (PCOS) have greater cardiac risk factor clustering but the link with mortality is incompletely described. Objective: To evaluate outcomes in 295 postmenopausal women enrolled in the National Institutes of Health–National Heart, Lung, and Blood Institute (NIH-NHLBI) sponsored Women's Ischemia Syndrome Evaluation (WISE) study according to clinical features of PCOS. Materials and Methods: A total of 25/295 (8%) women had clinical features of PCOS defined by a premenopausal history of irregular menses and current biochemical evidence of hyperandrogenemia, defined as the top quartile of androstenedione (≥701 pg/mL), testosterone (≥30.9 ng/dL), or free testosterone (≥4.5 pg/mL). Cox proportional hazard model estimated death (n = 80). Results: Women with clinical features of PCOS had an earlier menopause (p = 0.01), were more often smokers (p < 0.04), and trended toward more angiographic coronary artery disease (CAD) (p = 0.07) than women without these fe...

Strategies and methods to study female-specific cardiovascular health and disease: a guide for clinical scientists.

Abstract: In 2001, the Institute of Medicine’s (IOM) report, “Exploring the Biological Contributions to Human Health: Does Sex Matter?” advocated for better understanding of the differences in human diseases between the sexes, with translation of these differences into clinical practice. Sex differences are well documented in the prevalence of cardiovascular (CV) risk factors, the clinical manifestation and incidence of cardiovascular disease (CVD), and the impact of risk factors on outcomes. There are also physiologic and psychosocial factors unique to women that may affect CVD risk, such as issues related to reproduction. The Society for Women’s Health Research (SWHR) CV Network compiled an inventory of sex-specific strategies and methods for the study of women and CV health and disease across the lifespan. References for methods and strategy details are provided to gather and evaluate this information. Some items comprise robust measures; others are in development. To address female-specific CV health and disease in population, physiology, and clinical trial research, data should be collected on reproductive history, psychosocial variables, and other factors that disproportionately affect CVD in women. Variables related to reproductive health include the following: age of menarche, menstrual cycle regularity, hormone levels, oral contraceptive use, pregnancy history/complications, polycystic ovary syndrome (PCOS) components, menopause age, and use and type of menopausal hormone therapy. Other factors that differentially affect women’s CV risk include diabetes mellitus, autoimmune inflammatory disease, and autonomic vasomotor control. Sex differences in aging as well as psychosocial variables such as depression and stress should also be considered. Women are frequently not included/enrolled in mixed-sex CVD studies; when they are included, information on these variables is generally not collected. These omissions limit the ability to determine the role of sex-specific contributors to CV health and disease. Lack of sex-specific knowledge contributes to the CVD health disparities that women face. The purpose of this review is to encourage investigators to consider ways to increase the usefulness of physiological and psychosocial data obtained from clinical populations, in an effort to improve the understanding of sex differences in clinical CVD research and health-care delivery for women and men.

Noninvasive Imaging to Evaluate Women With Stable Ischemic Heart Disease

Abstract: Declines in cardiovascular deaths have been dramatic for men but occur significantly less in women. Among patients with symptomatic ischemic heart disease (IHD), women experience relatively worse outcomes compared with their male counterparts. Evidence to date has failed to adequately explore unique female imaging targets and their correlative signs and symptoms of IHD as major determinants of IHD risk. We highlight sex-specific anatomic and functional differences in contemporary imaging and introduce imaging approaches that leverage refined targets that may improve IHD risk prediction and identify potential therapeutic strategies for symptomatic women.

Prognostic Determinants of Coronary Atherosclerosis in Stable Ischemic Heart Disease: Anatomy, Physiology, or Morphology?

Abstract: Risk stratification in patients with stable ischemic heart disease is essential to guide treatment decisions. In this regard, whether coronary anatomy, physiology, or plaque morphology is the best determinant of prognosis (and driver an effective therapeutic risk reduction) remains one of the greatest ongoing debates in cardiology. In the present report, we review the evidence for each of these characteristics and explore potential algorithms that may enable a practical diagnostic and therapeutic strategy for the management of patients with stable ischemic heart disease.

HIV, highly active antiretroviral therapy and the heart: a cellular to epidemiological review.

Abstract: The advent of potent highly active antiretroviral therapy (HAART) for persons infected with HIV-1 has led to a "new" chronic disease with complications including cardiovascular disease (CVD). CVD is a significant cause of morbidity and mortality in persons with HIV infection. In addition to traditional risk factors such as smoking, hypertension, insulin resistance and dyslipidaemia, infection with HIV is an independent risk factor for CVD. This review summarizes: (1) the vascular and nonvascular cardiac manifestations of HIV infection; (2) cardiometabolic effects of HAART; (3) atherosclerotic cardiovascular disease (ASCVD) risk assessment, prevention and treatment in persons with HIV-1 infection.

Discordance Between Appropriate Use Criteria for Nuclear Myocardial Perfusion Imaging From Different Specialty Societies: A Potential Concern for Health Policy.

Abstract: Importance Appropriate use criteria (AUC) assist health care professionals in making decisions about procedures and diagnostic testing. In some cases, multiple AUC exist for a single procedure or test. To date, the extent of agreement between multiple AUC has not been evaluated. Objective To measure discordance between the American College of Cardiology Foundation (ACCF) AUC and the American College of Radiology (ACR) Appropriateness Criteria for gauging the appropriateness of nuclear myocardial perfusion imaging. Design, Setting, and Participants Retrospective cohort study at an academically affiliated Veterans Affairs medical center. Participants were Veteran patients who underwent nuclear myocardial perfusion imaging between December 2010 and July 2011 with rating of appropriateness by the ACCF and ACR criteria. Analysis was performed in March 2015. Main Outcomes and Measures The primary outcome was the agreement of appropriateness category as measured by κ statistic. The secondary outcome was a comparison of nuclear myocardial perfusion imaging results and frequency of ischemia across appropriateness categories for the 2 rating methods. Results Of 67 indications in the ACCF AUC, 35 (52.2%) could not be matched to an ACR rating, 18 (26.9%) had the same appropriateness category, and 14 (20.9%) disagreed on appropriateness. The study cohort comprised 592 individuals. Their mean (SD) age was 62.6 (9.4) years, and 570 of 592 (96.2%) were male. When applied to the patient cohort, 111 patients (18.8%) could not be matched to an ACR rating, 349 patients (59.0%) had the same appropriateness category for the ACR and ACCF methods, and 132 patients (22.3%) were discordant. Overall, the agreement of appropriateness between the 2 methods was poor (κ = 0.34,P Conclusions and Relevance Substantial discordance may exist between methods for assessing the appropriateness of advanced imaging tests. Discordance in methods may translate into differences in clinically relevant outcomes, such as the detection of myocardial ischemia.

Coronary calcium scoring for long-term mortality prediction in patients with and without a family history of coronary disease

Abstract: Objective Minimal data are available regarding the long-term mortality risk of subclinical atherosclerosis using coronary artery calcium (CAC) scoring among patients with a family history (FH) of coronary artery disease (CAD). The aim of the present analysis was to assess the prognostic utility of CAC scoring among cohorts of young and older patients with and without a FH of CAD. Methods A total of 9715 consecutive asymptomatic patients, free of known CAD, underwent CAC scoring for cardiovascular risk assessment. The primary end point was all-cause mortality, with a median follow-up of 14.6 years. Unadjusted and risk-factor adjusted Cox proportional hazard modelling was employed. We calculated the area under the curve (AUC) from receiver operating characteristics analysis. Results 15-year all-cause mortality rates ranged from 4.7% to 25.0% for FH patients and from 5.0% to 38.0% for non-FH patients with CAC scores of 0 to >400 (p 60 years with FH of CAD, there was a significant improvement in the AUC with CAC over CAD risk factors (AUC: 0.539 vs 0.725, p Conclusion CAC effectively stratified mortality risk of patients with and without FH of CAD. However, for younger and lower-risk FH cohorts, CAC screening did not provide additive prognostic information beyond that of the traditional cardiac risk factors.

Gender Differences in Radiation Dose From Nuclear Cardiology Studies Across the World: Findings From the INCAPS Registry.

Abstract: Objectives The aim of this study was to investigate gender-based differences in nuclear cardiology practice globally, with a particular focus on laboratory volume, radiation dose, protocols, and best practices. Background It is unclear whether gender-based differences exist in radiation exposure for nuclear cardiology procedures. Methods In a large, multicenter, observational, cross-sectional study encompassing 7,911 patients in 65 countries, radiation effective dose was estimated for each examination. Patient-level best practices relating to radiation exposure were compared between genders. Analysis of covariance was used to determine any difference in radiation exposure according to gender, region, and the interaction between gender and region. Linear, logistic, and hierarchical regression models were developed to evaluate gender-based differences in radiation exposure and laboratory adherence to best practices. The study also included the United Nations Gender Inequality Index and Human Development Index as covariates in multivariable models. Results The proportion of myocardial perfusion imaging studies performed in women varied among countries; however, there was no significant correlation with the Gender Inequality Index. Globally, mean effective dose for nuclear cardiology procedures was only slightly lower in women (9.6 ± 4.5 mSv) than in men (10.3 ± 4.5 mSv; p Conclusions Despite significant worldwide variation in best practice use and radiation doses from nuclear cardiology procedures, only small differences were observed between genders worldwide. Regional variations noted in myocardial perfusion imaging use and radiation dose offer potential opportunities to address gender-related differences in delivery of nuclear cardiology care.

Implementing Multimodality Imaging in the Future.

Abstract: Multimodality imaging (MMI) has been at the forefront of discussions for more than a decade, and the 2015 Core Cardiology Training Symposium (COCATS) guidelines published in May 2015 [(1)][1] have further reinforced its importance. Nearly everyone agrees that MMI training is imperative, and most

Sex Differences in Cardiovascular Imaging.

Abstract: Heart disease is the leading cause of death for women in the United States, responsible for 1 in every 4 women’s deaths. Despite increases in awareness over the past decade, only 54% of women recognize that heart disease is their number 1 killer. Almost two-thirds (64%) of women who die suddenly

Optimising diagnostic accuracy with the exercise ECG: opportunities for women and men with stable ischaemic heart disease

Abstract: The exercise ECG is an integral part within the evaluation algorithm for diagnosis and risk stratification of patients with stable ischaemic heart disease (SIHD). There is evidence, both older and new, that the exercise ECG can be an effective and cost-efficient option for patients capable of performing at maximal levels of exercise with suitable resting ECG findings. In this review, we will highlight the major dilemmas in interpreting suspected coronary artery disease symptoms in women and identify optimal strategies for employing exercise ECG as a first-line diagnostic test in the SIHD evaluation algorithm. We will highlight current evidence as well as recent guideline statements on this subject. Trial registration number NCT01471522; Pre-results.

Measuring Diagnostic Health Care Costs in Stable Coronary Artery Disease: Should We Follow the Money?

Abstract: Mark and colleagues' economic analysis revealed minimal cost differences between strategies directed by the use of coronary CTA versus functional testing. The editorialists discuss these findings, ...

Use of bio-informatics assessment schema (BIAS) to improve diagnosis and prognosis of myocardial perfusion data: results from the NHLBI-sponsored women's ischemia syndrome evaluation (WISE).

Abstract: Background: We introduce an algorithmic approach to optimize diagnostic and prognostic value of gated cardiac single photon emission computed tomography (SPECT) and magnetic resonance (MR) myocardial perfusion imaging (MPI) modalities in women with suspected myocardial ischemia. The novel approach: bio-informatics assessment schema (BIAS) forms a mathematical model utilizing MPI data and cardiac metrics generated by one modality to predict the MPI status of another modality. The model identifies cardiac features that either enhance or mask the image-based evidence of ischemia. For each patient, the BIAS model value is used to set an appropriate threshold for the detection of ischemia. Methods: Women (n=130), with symptoms and signs of suspected myocardial ischemia, underwent MPI assessment for regional perfusion defects using two different modalities: gated SPECT and MR. To determine perfusion status, MR data were evaluated qualitatively (MRI QL ) and semi-quantitatively (MRI SQ ) while SPECT data were evaluated using conventional clinical criteria. Evaluators were masked to results of the alternate modality. These MPI status readings were designated “original”. Two regression models designated “BIAS” models were generated to model MPI status obtained with one modality (e.g., MRI) compared with a second modality (e.g., SPECT), but importantly, the BIAS models did not include the primary Original MPI reading of the predicting modality. Instead, the BIAS models included auxiliary measurements like left ventricular chamber volumes and myocardial wall thickness. For each modality, the BIAS model was used to set a progressive threshold for interpretation of MPI status. Women were then followed for 38±14 months for the development of a first major adverse cardiovascular event [MACE: CV death, nonfatal myocardial infarction (MI) or hospitalization for heart failure]. Original and BIAS-augmented perfusion status were compared in their ability to detect coronary artery disease (CAD) and for prediction of MACE. Results: Adverse events occurred in 14 (11%) women and CAD was present in 13 (10%). There was a positive correlation of maximum coronary artery stenosis and BIAS score for MRI and SPECT (P vs . the original for MRI SQ (0.78 vs . 0.54), MRI QL (0.78 vs . 0.64), SPECT (0.82 vs . 0.63) and the average of the three readings (0.80±0.02 vs . 0.60±0.05, P Conclusions: Increasing values of the BIAS score generated by both MRI and SPECT corresponded to the increasing prevalence of CAD and MACE. The BIAS-augmented detection of ischemia better predicted MACE compared with the Original reading for the MPI data for both MRI and SPECT.

Risk Detection Among Asymptomatic Patients With Diabetes: Is It Time for a Varied Approach?

Abstract: This issue of iJACC highlights several papers on the utility of cardiovascular imaging in diabetes. Over the past decade, there has been a plethora of observational registries and randomized trials evaluating the utility of noninvasive imaging, with recent reports examining prognostic risk among

Coronary Artery Calcium and Shared Decision Making.

Abstract: One of the important and least controversial concepts introduced by the 2013 American College of Cardiology and American Heart Association cholesterol guidelines, with a class IIa recommendation, is shared decision making (SDM) [(1)][1]: informing patients about all available options and seeking

Imaging Atherosclerosis for Global Predictive Health and Wellness.

Abstract: Age shifts have drastically changed the landscape of the U.S. population with nearly 1 in every 7 Americans being 65 years of age and older [(1)][1]. As the population ages, the impact on the health care system is expected to be dramatic, in particular as it relates to the care of patients with