Computed tomography angiography for the interventional cardiologist
01 Aug 2014-European Journal of Echocardiography (Oxford University Press)-Vol. 15, Iss: 8, pp 842-854
TL;DR: It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CCTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes.
Abstract: In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden. More recently, this technique has become mature, with a large body of evidence addressing its prognostic validation. In addition, CT angiography has moved from the field of ‘imagers’ and clinicians and entered the interventional cardiology arena, aiding in the planning of both coronary and structural heart interventions, being transcatheter aortic valve implantation one of its most successful examples. It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes. On the other hand, the increasing use of CCTA as a gatekeeper for invasive coronary angiography is expected to lead to an increase in the ratio of interventional to diagnostic procedures and significant changes in the daily cath-lab routine. In a foreseeable future, cath-labs will probably offer an invasive procedure only to patients expected to undergo an intervention, perhaps becoming in this change true interventional-labs.
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TL;DR: Various plaque metrics obtained by cardiac CT predict provocable myocardial ischemia by CT perfusion imaging through their association with maximum percent stenosis, while none had significant incremental value.
Abstract: Objectives This study sought to investigate the performance of various cardiac computed tomography (CT)–derived atherosclerotic plaque metrics for predicting provocable myocardial ischemia. Background The association of coronary arterial diameter stenosis with myocardial ischemia is only modest, but cardiac CT provides several other, readily available atherosclerosis metrics, which may have incremental value. Methods The study analyzed 873 nonstented coronary arteries and their myocardial perfusion territories in 356 patients (mean 62 years of age) enrolled in the CORE320 (Coronary Artery Evaluation using 320-row Multidetector Computed Tomography Angiography and Myocardial Perfusion) study. Myocardial perfusion defects in static CT perfusion imaging were graded at rest and after adenosine in 13 myocardial segments using a 4-point scale. The summed difference score was calculated by subtracting the summed rest score from the summed stress score. Reversible ischemia was defined as summed difference score ≥1. In a sensitivity analysis, results were also provided using single-photon emission computed tomography (SPECT) as the reference standard. Vessel based predictor variables included maximum percent diameter stenosis, lesion length, coronary calcium score, maximum cross-sectional calcium arc, percent atheroma volume (PAV), low-attenuation atheroma volume, positive (external) vascular remodeling, and subjective impression of “vulnerable plaque.” The study used logistic regression models to assess the association of plaque metrics with myocardial ischemia. Results In univariate analysis, all plaque metrics were associated with reversible ischemia. In the adjusted logistic model, only maximum percent diameter stenosis (1.26; 95% confidence interval: 1.15 to 1.38) remained an independent predictor. With SPECT as outcome variable, PAV and “vulnerable” plaque remained predictive after adjustment. In vessels with intermediate stenosis (40% to 70%), no single metric had clinically meaningful incremental value. Conclusions Various plaque metrics obtained by cardiac CT predict provocable myocardial ischemia by CT perfusion imaging through their association with maximum percent stenosis, while none had significant incremental value. With SPECT as reference standard, PAV and “vulnerable plaque” remained predictors of ischemia after adjustment but the predictive value added to stenosis assessment alone was small.
23 citations
TL;DR: The integration of a novel non-invasive functional coronary assessment with the angiographic risk score in patients with multivessel CAD further refines the identification of patients at risk and provides a recommendation for the Heart Team regarding the treatment strategy.
Abstract: Since the early days of coronary angiography, the extension and severity of coronary artery disease (CAD) have been used for risk stratification. The SYNTAX score objectively characterizes CAD in patients with multivessel disease. Furthermore, recalculating the SYNTAX score by the incorporation of the functional component coronary stenosis (i.e., FFR) increases the discrimination for the risk of adverse events. The calculation of the SYNTAX score derived from non-invasive modalities such as coronary computed tomography angiography (CTA) has emerged as a mean to obtain the SYNTAX score before invasive cardiac catheterization. Likewise, the computation of the non-invasive fractional flow reserve CT (FFRCT) allows for the calculation of the non-invasive functional SYNTAX score. Ultimately, the combination of anatomical and functional evaluations with clinical factors further refines the identification of patients at risk and provides a recommendation for the Heart Team regarding the treatment strategy (i.e., PCI or CABG) based on the predicted 4-year mortality. The purpose of this review is to describe the integration of a novel non-invasive functional coronary assessment with the angiographic risk score in patients with multivessel CAD.
20 citations
TL;DR: This review article outlines the use of MSCT as a tool for diagnosis of structural heart interventions, as well as patient selection, pre-procedural planning, device sizing and post-Procedural assessment.
Abstract: Transcatheter cardiac interventions are a fast evolving field. The past decade has seen the development of transcatheter aortic valve replacement, transcatheter mitral valve repair and replacement, septal defect closure devices and left atrial appendage closure devices for thromboprophylaxis. More than ever, medical imaging is taking a central role in the care of patients with structural heart disease. In this review article we outline the use of MSCT as a tool for diagnosis of structural heart interventions, as well as patient selection, pre-procedural planning, device sizing and post-procedural assessment. We focus on procedures targeting the aortic valve, the mitral valve, the inter-atrial septum and the left atrial appendage.
8 citations
TL;DR: The ability of CCTA to provide comprehensive assessment of a patient with suspected CAD is discussed, including functional techniques of stress-rest myocardial perfusion assessment using a vasodilator and a purely post-processing approach that assesses fractional flow reserve derived by CCTa.
Abstract: Cardiac computed tomography angiography (CCTA) has evolved into a versatile imaging modality that can depict atherosclerosis burden, determine functional significance of a stenotic lesion, and guide the management and treatment of stable coronary artery disease.1 With newer-generation scanners, diagnostic CCTA can be obtained in the majority of patients with a very acceptable radiation dose. We discuss the ability of CCTA to provide comprehensive assessment of a patient with suspected CAD, including functional techniques of stress-rest myocardial perfusion assessment using a vasodilator and a purely post-processing approach that assesses fractional flow reserve derived by CCTA. In addition, recent data validated the role of CCTA in managing stable patients with chest pain and suspected CAD, serving as a gatekeeper for invasive coronary angiogram as well as optimizing the preprocedural planning of percutaneous coronary revascularization and coronary artery bypass surgery.
4 citations
TL;DR: Single-heartbeat free-breathing CCTA can be performed for patients with high HRv using 16-cm wide-detector CT scanner to achieve diagnostic image quality with low radiation dose.
Abstract: OBJECTIVE The aim of this study was to investigate radiation dose and image quality of coronary computed tomography (CT) angiography (CCTA) for patients with high heart rate variability (HRv) using 16-cm wide-detector CT scanner. METHODS One hundred sixty-six patients with uncontrolled heart rate underwent CCTA on a 16-cm wide-detector CT system and were divided into 2 groups based on their HRv for analysis: group A (n = 95, HRv ≤10 beats/min [bpm]) and group B (n = 71, HRv >10 bpm). Images in both groups were reconstructed with motion correction algorithm. Subjective and objective image qualities were analyzed. RESULTS There were no significant differences in age, body mass index, and heart rate (68.1 ± 11.4 vs 67.6 ± 12.3 bpm) between the 2 groups (P > 0.05). However, group B had significantly higher HRv than group A (33.5 ± 24.4 vs 7.8 ± 1.2 bpm, P < 0.001). All images were acceptable for clinical diagnosis. Compared with group A, image quality scores in group B decreased slightly (4.1 ± 0.5 vs 4.0 ± 0.6). However, the difference was not statistically significant. The mean effective doses were both relatively low at 2.2 ± 1.1 mSv in group A and 2.6 ± 1.4 mSv in group B. CONCLUSIONS Single-heartbeat free-breathing CCTA can be performed for patients with high HRv using 16-cm wide-detector CT scanner to achieve diagnostic image quality with low radiation dose.
3 citations
References
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TL;DR: Among patients who have recently had an acute coronary syndrome, an intensive lipid-lowering statin regimen provides greater protection against death or major cardiovascular events than does a standard regimen.
Abstract: background Lipid-lowering therapy with statins reduces the risk of cardiovascular events, but the optimal level of low-density lipoprotein (LDL) cholesterol is unclear. methods We enrolled 4162 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and compared 40 mg of pravastatin daily (standard therapy) with 80 mg of atorvastatin daily (intensive therapy). The primary end point was a composite of death from any cause, myocardial infarction, documented unstable angina requiring rehospitalization, revascularization (performed at least 30 days after randomization), and stroke. The study was designed to establish the noninferiority of pravastatin as compared with atorvastatin with respect to the time to an end-point event. Follow-up lasted 18 to 36 months (mean, 24). results The median LDL cholesterol level achieved during treatment was 95 mg per deciliter (2.46 mmol per liter) in the standard-dose pravastatin group and 62 mg per deciliter (1.60 mmol per liter) in the high-dose atorvastatin group (P<0.001). Kaplan–Meier estimates of the rates of the primary end point at two years were 26.3 percent in the pravastatin group and 22.4 percent in the atorvastatin group, reflecting a 16 percent reduction in the hazard ratio in favor of atorvastatin (P=0.005; 95 percent confidence interval, 5 to 26 percent). The study did not meet the prespecified criterion for equivalence but did identify the superiority of the more intensive regimen. conclusions Among patients who have recently had an acute coronary syndrome, an intensive lipidlowering statin regimen provides greater protection against death or major cardiovascular events than does a standard regimen. These findings indicate that such patients benefit from early and continued lowering of LDL cholesterol to levels substantially below current target levels.
4,203 citations
"Computed tomography angiography for..." refers background in this paper
...CAD, which changes natural history and reduces the risk of subsequent cardiovascular events.(46,47) In the multicentre PROSPECT study,(47) a large plaque burden, a...
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TL;DR: Guidelines and Expert Consensus Documents aim to present management recommendations based on all of the relevant evidence on a particular subject in order to help physicians select the best possible management strategies for the individual patient suffering from a specific condition, taking into account the impact on outcome and also the risk–benefit ratio of a particular diagnostic or therapeutic procedure.
Abstract: Guidelines and Expert Consensus Documents aim to present management recommendations based on all of the relevant evidence on a particular subject in order to help physicians select the best possible management strategies for the individual patient suffering from a specific condition, taking into account the impact on outcome and also the risk–benefit ratio of a particular diagnostic or therapeutic procedure. Numerous studies have demonstrated that patient outcomes improve when guideline recommendations, based on the rigorous assessment of evidence-based research, are applied in clinical practice.
A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. The profusion of documents can put at stake the authority and credibility of guidelines, particularly if discrepancies appear between different documents on the same issue, as this can lead to confusion in the minds of physicians. In order to avoid these pitfalls, the ESC and other organizations have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents. The ESC recommendations for guidelines production can be found on the ESC website.1 It is beyond the scope of this preamble to recall all but the basic rules.
In brief, the ESC appoints experts in the field to carry out a comprehensive review of the literature, with a view to making a critical evaluation of the use of diagnostic and therapeutic procedures and assessing the risk–benefit ratio of the therapies recommended for management and/or prevention of a given condition. Estimates of expected health outcomes are included, where data exist. The strength of evidence for or against particular procedures or treatments is weighed according to predefined scales for grading recommendations and levels of evidence, as outlined in what follows.
The Task Force members of the writing panels, …
3,707 citations
TL;DR: Guidelines summarize and evaluate all evidence available on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome.
Abstract: ACE
: angiotensin-converting enzyme
AF
: atrial fibrillation
aPTT
: activated partial thromboplastin time
AR
: aortic regurgitation
ARB
: angiotensin receptor blockers
AS
: aortic stenosis
AVR
: aortic valve replacement
BNP
: B-type natriuretic peptide
BSA
: body surface area
CABG
: coronary artery bypass grafting
CAD
: coronary artery disease
CMR
: cardiac magnetic resonance
CPG
: Committee for Practice Guidelines
CRT
: cardiac resynchronization therapy
CT
: computed tomography
EACTS
: European Association for Cardio-Thoracic Surgery
ECG
: electrocardiogram
EF
: ejection fraction
EROA
: effective regurgitant orifice area
ESC
: European Society of Cardiology
EVEREST
: (Endovascular Valve Edge-to-Edge REpair STudy)
HF
: heart failure
INR
: international normalized ratio
LA
: left atrial
LMWH
: low molecular weight heparin
LV
: left ventricular
LVEF
: left ventricular ejection fraction
LVEDD
: left ventricular end-diastolic diameter
LVESD
: left ventricular end-systolic diameter
MR
: mitral regurgitation
MS
: mitral stenosis
MSCT
: multi-slice computed tomography
NYHA
: New York Heart Association
PISA
: proximal isovelocity surface area
PMC
: percutaneous mitral commissurotomy
PVL
: paravalvular leak
RV
: right ventricular
rtPA
: recombinant tissue plasminogen activator
SVD
: structural valve deterioration
STS
: Society of Thoracic Surgeons
TAPSE
: tricuspid annular plane systolic excursion
TAVI
: transcatheter aortic valve implantation
TOE
: transoesophageal echocardiography
TR
: tricuspid regurgitation
TS
: tricuspid stenosis
TTE
: transthoracic echocardiography
UFH
: unfractionated heparin
VHD
: valvular heart disease
3DE
: three-dimensional echocardiography
Guidelines summarize and evaluate all evidence available, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well …
3,608 citations
Harvard University1, Aarhus University2, University of Texas at Austin3, Memorial Hermann Texas Medical Center4, National and Kapodistrian University of Athens5, University of Kentucky6, Utrecht University7, Icahn School of Medicine at Mount Sinai8, Tufts University9, Tulane University10, Armed Forces Institute of Pathology11, University of Washington12, Stanford University13, Erasmus University Rotterdam14, University of Turku15, University of Münster16, Mayo Clinic17, Emory University18, University of Bristol19, University of Ulm20, Veterans Health Administration21, University of Texas Health Science Center at Houston22, University of California, Los Angeles23, University of Pavia24, Pfizer25, University of Texas Southwestern Medical Center26, Lenox Hill Hospital27, Baylor College of Medicine28, University of Maryland, Baltimore29, Karolinska Institutet30, University of Chicago31, Cedars-Sinai Medical Center32, Northwestern University33, Indiana University34
TL;DR: The term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future and a quantitative method for cumulative risk assessment of vulnerable patients needs to be developed.
Abstract: Atherosclerotic cardiovascular disease results in >19 million deaths annually, and coronary heart disease accounts for the majority of this toll. Despite major advances in treatment of coronary heart disease patients, a large number of victims of the disease who are apparently healthy die suddenly without prior symptoms. Available screening and diagnostic methods are insufficient to identify the victims before the event occurs. The recognition of the role of the vulnerable plaque has opened new avenues of opportunity in the field of cardiovascular medicine. This consensus document concludes the following. (1) Rupture-prone plaques are not the only vulnerable plaques. All types of atherosclerotic plaques with high likelihood of thrombotic complications and rapid progression should be considered as vulnerable plaques. We propose a classification for clinical as well as pathological evaluation of vulnerable plaques. (2) Vulnerable plaques are not the only culprit factors for the development of acute coronary syndromes, myocardial infarction, and sudden cardiac death. Vulnerable blood (prone to thrombosis) and vulnerable myocardium (prone to fatal arrhythmia) play an important role in the outcome. Therefore, the term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future. (3) A quantitative method for cumulative risk assessment of vulnerable patients needs to be developed that may include variables based on plaque, blood, and myocardial vulnerability. In Part I of this consensus document, we cover the new definition of vulnerable plaque and its relationship with vulnerable patients. Part II of this consensus document focuses on vulnerable blood and vulnerable myocardium and provide an outline of overall risk assessment of vulnerable patients. Parts I and II are meant to provide a general consensus and overviews the new field of vulnerable patient. Recently developed assays (eg, C-reactive protein), imaging techniques (eg, CT and MRI), noninvasive electrophysiological tests (for vulnerable myocardium), and emerging catheters (to localize and characterize vulnerable plaque) in combination with future genomic and proteomic techniques will guide us in the search for vulnerable patients. It will also lead to the development and deployment of new therapies and ultimately to reduce the incidence of acute coronary syndromes and sudden cardiac death. We encourage healthcare policy makers to promote translational research for screening and treatment of vulnerable patients.
2,719 citations
TL;DR: In patients who presented with an acute coronary syndrome and underwent percutaneous coronary intervention, major adverse cardiovascular events occurring during follow-up were equally attributable to recurrence at the site of culprit lesions and to nonculprit lesions.
Abstract: A b s t r ac t Background Atherosclerotic plaques that lead to acute coronary syndromes often occur at sites of angiographically mild coronary-artery stenosis. Lesion-related risk factors for such events are poorly understood. Methods In a prospective study, 697 patients with acute coronary syndromes underwent three-vessel coronary angiography and gray-scale and radiofrequency intravascular ultrasonographic imaging after percutaneous coronary intervention. Subsequent major adverse cardiovascular events (death from cardiac causes, cardiac arrest, myocardial infarction, or rehospitalization due to unstable or progressive angina) were adjudicated to be related to either originally treated (culprit) lesions or untreated (nonculprit) lesions. The median follow-up period was 3.4 years. Results The 3-year cumulative rate of major adverse cardiovascular events was 20.4%. Events were adjudicated to be related to culprit lesions in 12.9% of patients and to nonculprit lesions in 11.6%. Most nonculprit lesions responsible for follow-up events were angiographically mild at baseline (mean [±SD] diameter stenosis, 32.3±20.6%). However, on multivariate analysis, nonculprit lesions associated with recurrent events were more likely than those not associated with recurrent events to be characterized by a plaque burden of 70% or greater (hazard ratio, 5.03; 95% confidence interval [CI], 2.51 to 10.11; P<0.001) or a minimal luminal area of 4.0 mm 2 or less (hazard ratio, 3.21; 95% CI, 1.61 to 6.42; P = 0.001) or to be classified on the basis of radiofrequency intravascular ultrasonography as thin-cap fibroatheromas (hazard ratio, 3.35; 95% CI, 1.77 to 6.36; P<0.001). Conclusions In patients who presented with an acute coronary syndrome and underwent percutaneous coronary intervention, major adverse cardiovascular events occurring during follow-up were equally attributable to recurrence at the site of culprit lesions and to nonculprit lesions. Although nonculprit lesions that were responsible for unanticipated events were frequently angiographically mild, most were thin-cap fibroatheromas or were characterized by a large plaque burden, a small luminal area, or some combination of these characteristics, as determined by gray-scale and radiofrequency intravascular ultrasonography. (Funded by Abbott Vascular and Volcano; ClinicalTrials.gov number, NCT00180466.)
2,649 citations