Lipoprotein(a) levels are associated with aortic valve calcification in asymptomatic patients with familial hypercholesterolaemia.

OBJECTIVES: Lipoprotein(a) [Lp(a)] is an independent risk factor for aortic valve stenosis and aortic valve calcification (AVC) in the general population. In this study, we determined the association between AVC and both plasma Lp(a) levels and apolipoprotein(a) [apo(a)] kringle IV repeat polymorphisms in asymptomatic statin-treated patients with heterozygous familial hypercholesterolaemia (FH). METHODS: A total of 129 asymptomatic heterozygous FH patients (age 40-69 years) were included in this study. AVC was detected using computed tomography scanning. Lp(a) concentration and apo(a) kringle IV repeat number were measured using immunoturbidimetry and immunoblotting, respectively. Univariate and multivariate logistic regression were used to assess the association between Lp(a) concentration and the presence of AVC. RESULTS: Aortic valve calcification was present in 38.2% of patients, including three with extensive AVC (>400 Agatston units). Lp(a) concentration was significantly correlated with gender, number of apo(a) kringle IV repeats and the presence and severity of AVC, but not with coronary artery calcification (CAC). AVC was significantly associated with plasma Lp(a) level, age, body mass index, blood pressure, duration of statin use, cholesterol-year score and CAC score. After adjustment for all significant covariables, plasma Lp(a) concentration remained a significant predictor of AVC, with an odds ratio per 10-mg dL(-1) increase in Lp(a) concentration of 1.11 (95% confidence interval 1.01-1.20, P = 0.03). CONCLUSION: In asymptomatic statin-treated FH patients, plasma Lp(a) concentration is an independent risk indicator for AVC.

First-line evaluation of coronary artery disease with coronary calcium scanning or exercise electrocardiography.

BACKGROUND: Although conventional (CAG) and computed tomography angiography (CTA) are reliable diagnostic modalities for exclusion of obstructive coronary artery disease (CAD), they are costly and with considerable exposure to radiation and contrast media. We compared the accuracy of coronary calcium scanning (CCS) and exercise electrocardiography (X-ECG) as less expensive and non-invasive means to rule out obstructive CAD. METHODS: In a rapid-access chest pain clinic, 791 consecutive patients with stable chest pain were planned to undergo X-ECG and dual-source CTA with CCS. According to the Duke pre-test probability of CAD patients were classified as low (<30%), intermediate (30-70%) or high risk (>70%). Angiographic obstructive CAD (>50% stenosis by CAG or CTA) was found in 210/791 (27%) patients, CAG overruling any CTA results. RESULTS: Obstructive CAD was found in 12/281 (4%) patients with no coronary calcium and in 73/319 (23%) with a normal X-ECG (p<0.001). No coronary calcium was associated with a substantially lower likelihood ratio compared to X-ECG; 0.11, 0.13 and 0.13 vs. 0.93, 0.55 and 0.46 in the low, intermediate and high risk group. In low risk patients a negative calcium score reduced the likelihood of obstructive CAD to less than 5%, removing the need for further diagnostic work-up. CCS could be performed in 754/756 (100%) patients, while X-ECG was diagnostic in 448/756 (59%) patients (p<0.001). CONCLUSIONS: In real-world patients with stable chest pain CCS is a reliable initial test to rule out obstructive CAD and can be performed in virtually all patients.

Diagnostic performance of exercise bicycle testing and single-photon emission computed tomography: comparison with 64-slice computed tomography coronary angiography.

To conduct a comparison of the diagnostic performance of exercise bicycle testing and single-photon emission computed tomography (SPECT) with computed tomography coronary angiography (CTCA) for the detection of obstructive coronary artery disease (CAD) in patients with stable angina. 376 symptomatic patients (254 men, 122 women, mean age 60.4 ± 10.0 years) referred for noninvasive stress testing (exercise bicycle test and/or SPECT) and invasive coronary angiography were included. All patients underwent additional 64-slice CTCA. The diagnostic performance of exercise bicycle testing (ST segment depression), SPECT (reversible perfusion defect) and CTCA (≥50% lumen diameter reduction) was presented as sensitivity, specificity, positive and negative predictive value (PPV and NPV) to detect or rule out obstructive CAD with quantitative coronary angiography as reference standard. Comparisons of exercise bicycle testing versus CTCA (n = 334), and SPECT versus CTCA (n = 61) were performed. The diagnostic performance of exercise bicycle testing was significantly (P value < 0.001) lower compared to CTCA: sensitivity of 76% (95% CI, 71-82) vs. 100% (95% CI, 97-100); specificity of 47% (95% CI, 36-58) vs. 74% (95% CI, 63-82). We observed a PPV of 70% (95% CI, 65-75) vs. 91% (95% CI, 87-94); and NPV of 30% (95%, 25-35) vs. 99% (95%, 90-100). There was a statistically significant difference in sensitivity (P value < 0.05) between SPECT and CTCA: 89% (95% CI, 75-96) vs. 98% (95% CI, 87-100); but not in specificity (P value > 0.05): 77% (95% CI, 50-92) vs. 82% (95% CI, 56-95). We observed a PPV of 91% (95% CI, 77-97) vs. 93% (95% CI, 81-98); and NPV of 72% (95%, 46-89) vs. 93% (95%, 66-100). SPECT and CTCA yielded higher diagnostic performance compared to traditional exercise bicycle testing for the detection and rule out of obstructive CAD in patients with stable angina.

The role of multi-slice computed tomography in stable angina management: a current perspective.

Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD. However, because CTCA is moderately predictive for indicating the functional significance of a lesion, the combination of anatomic and functional imaging will become increasingly important. The technology will continue to improve with better spatial and temporal resolution at low radiation exposure, and CTCA may eventually replace invasive coronary angiography. The establishment of the precise role of CTCA in the diagnosis and management of patients with stable angina requires high-quality randomised study designs with clinical outcomes as a primary outcome.

Cardiac magnetic resonance imaging in stable ischaemic heart disease.

Cardiac magnetic resonance imaging (CMR) is a new robust versatile non-invasive imaging technique that can detect global and regional myocardial dysfunction, presence of myocardial ischaemia and myocardial scar tissue in one imaging session without radiation, with superb spatial and temporal resolution, inherited three-dimensional data collection and with relatively safe contrast material. The reproducibility of CMR is high which makes it possible to use this technique for serial assessment to evaluate the effect of revascularisation therapy in patients with ischaemic heart disease.

Combining noninvasive anatomical imaging with invasive functional information: an unconventional but appropriate hybrid approach.

CT coronary angiography (CTCA) allows accurate noninvasive imaging of the coronary arteries. As illustrated by this case report, the threedimensional information provided by this technique might be of value to resolve complex coronary pathology encountered in the cathlab. However, the limitations inherent to an anatomical test also apply for CTCA, and bring in the need for functional information to ensure adequate patient management. (Neth Heart J 2009;17:292-4.).

Coronary artery anomalies detected by MSCT-coronary angiography in the adult.

BACKGROUND: Before coronary evaluation by modern imaging techniques was feasible, premorbid diagnoses of coronary artery anomalies (CAAs) were usually made fortuitously by invasive coronary angiography (ICA). However, this technique is limited by its invasive and projectional nature. Coronary magnetic resonance angiography (CMRA) and multi-slice computed tomography (MSCT) broadened clinical information by enabling visualisation of the coronary arteries in their anatomical environment. METHODS: This case series visualises and reviews anomalous coronary artery from the opposite sinus (ACAOS) and coronary artery fistulae. All CAAs were detected by means of 64-slice dual source computed tomography after 1000 cardiac scans at the Erasmus MC, Rotterdam, the Netherlands. RESULTS: Eight ACAOS cases, one anomalous left coronary artery from the pulmonary artery (ALCAPA) and one congenital aneurysm of an aortic sinus were found. Seven out often detected CAAs were considered malignant whereas three CAAs of the ACAOS type (retroaortic path) were considered benign. Significant coronary artery disease was found in three out of eight ACAOS cases. In one of the ACAOS cases complete evaluation of the anomalous coronary artery was limited by motion artifacts. All five cases of right ACAOS were referred for MSCT because the right coronary artery could not be located by invasive angiography. CONCLUSION: All CAAs were easy to diagnose because of 3D imaging and high temporal and spatial resolution. High resolution made it possible to not only depict coronary artery abnormalities, but also to quantify luminal and vessel properties such as stenosis grade, aspects of plaque, anomalous vessel length, luminal area ratio and the asymmetry ratio. Because of its comprehensiveness, MSCT can be an effective imaging modality in patients suspected of coronary artery abnormalities caused by coronary artery disease, CAAs, or a combination of both. (Neth Heart J 2008;16:369-75.).

Dual source coronary computed tomography angiography for detecting in-stent restenosis.

OBJECTIVE: To evaluate the performance of dual source CT coronary angiography (DSCT-CA) in the detection of in-stent restenosis (>or=50% luminal narrowing) in symptomatic patients referred for conventional angiography (CA). DESIGN/ PATIENTS: 100 patients (78 males, age 62 (SD 10)) with chest pain were prospectively evaluated after coronary stenting. DSCT-CA was performed before CA. SETTING: Many patients undergo coronary artery stenting; availability of a non-invasive modality to detect in-stent restenosis would be desirable. RESULTS: Average heart rate (HR) was 67 (SD 12) (range 46-106) bpm. There were 178 stented lesions. The interval between stenting and inclusion in the study was 35 (SD 41) (range 3-140) months. 39/100 (39%) patients had angiographically proven restenosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DSCT-CA, calculated in all stents, were 94%, 92%, 77% and 98%, respectively. Diagnostic performance at HR <70 bpm (n = 69; mean 58 bpm) was similar to that at HR >or=70 bpm (n = 31; mean 78 bpm); diagnostic performance in single stents (n = 95) was similar to that in overlapping stents and bifurcations (n = 83). In stents >or=3.5 mm (n = 78), sensitivity, specificity, PPV, NPV were 100%; in 3 mm stents (n = 59), sensitivity and NPV were 100%, specificity 97%, PPV 91%; in stents or=3.5 mm was significantly higher than in stents

Multislice computed tomography coronary angiography: clinical applications.

Cardiac and coronary computed tomography (CT) is becoming increasingly common in clinical practice. Even if there is no well-established evidence, this diagnostic modality is so strong and effective and, in skilled hand, it can be readily used in clinical practice. After learning its potential and the technical limits, this tool could be used for risk stratification as well as for revascularization evaluation. In this review, we will describe the results of present literature, clinical applications at present considered suitable to CT technology (i.e. 64-slice and dual-source scanners) and future applications and innovations.

Spiral multislice computed tomography coronary angiography: a current status report.

Multislice computed tomography coronary angiography (MSCT-CA) has emerged as a powerful noninvasive diagnostic modality to visualize the coronary arteries and to detect significant coronary stenoses. The latest generation 64-slice computed tomography (CT) scanners is a robust technique which allows high-resolution, isotropic, nearly motion-free coronary imaging. Coronary stenoses are detected with high sensitivity and a normal scan accurately rules out the presence of a coronary stenosis. With the introduction of further novel concepts in CT-technology one may expect that MSCT-CA will become a clinically used diagnostic tool.

[Background and application of multi-slice CT in the diagnosis of coronary artery disease]. / Achtergrond en toepassing van 'multi-slice'-CT in de diagnostiek van coronairlijden.

Multi-slice CT coronary angiography is a rapidly developing noninvasive diagnostic technique that can be used to detect coronary stenosis. Detection of coronary stenosis by coronary angiography is usually hindered by limited image quality, motion artefacts caused by heart contractions, and artefacts caused by extensive calcification. In addition, the radiation exposure is relatively great. Multi-slice CT coronary angiography, however, can reliably rule out coronary stenosis. At this time, multi-slice CT coronary angiography is not a routine part of the diagnosis of coronary artery disease. In the future, the target population for this technique may include asymptomatic high-risk patients and symptomatic low- or intermediate-risk patients for severe coronary artery disease.

Reduction in infarct size, but no functional improvement after bone marrow cell administration in a porcine model of reperfused myocardial infarction.

AIMS: Stem cell therapy after myocardial infarction (MI) has been studied in models of permanent coronary occlusion. We studied the effect of intracoronary administration of unselected bone marrow (BM) and mononuclear cells (MNC) in a porcine model of reperfused MI. METHODS AND RESULTS: In 34 swine, the left circumflex coronary artery was balloon-occluded for 2 h followed by reperfusion. Ten swine without MI served as controls. All swine underwent magnetic resonance imaging (MRI) 1 week post-MI. The next day, 10 of the 30 surviving MI swine received BM, 10 other MI swine received MNC, and the remaining MI swine received medium intracoronary. Four weeks later, all swine underwent a follow-up MRI. One week after MI, end-diastolic volume (92+/-16 mL) and left ventricular (LV) weight (78+/-12 g) were greater, whereas ejection fraction (40+/-8%) was lower than in controls (69+/-11 mL, 62+/-13 g, and 53+/-6%). Injection of BM or MNC had no effect on the MI-induced changes in global or regional LV-function. However, there was a significant reduction in infarct size 4 weeks after MNC injection (-6+/-3%) compared with the medium (-3+/-5%). CONCLUSION: Intracoronary injection of BM or MNC in swine does not improve regional or global LV-function 4 weeks after injection. However, a reduction in infarct-size was noted after MNC injection.

Non-invasive coronary angiography with 64-slice computed tomography.

Multislice computed tomography is a rapidly emerging technique for the non-invasive visualization of coronary arteries. Over the past 5 years several scanner generation were introduced with a progressive improvement in the diagnostic accuracy in the detection of coronary artery stenosis in selected patients populations. The introduction of 64-slice technology has further improved the diagnostic performance. This technique is at the edge of clinical implementation and, even though large clinical trials are still missing, an increased demand for these type of studies is observed all over the world. We describe our experience of more than 1 year with 64-slice CT coronary angiography providing clues on reasonable clinical applications.

Long term outcome after intracoronary beta radiation therapy.

OBJECTIVES: To determine the long term outcome after intracoronary beta radiation therapy (IRT). SETTING: Tertiary referral centre. METHODS: The rate of major adverse cardiac events (MACE) was retrospectively determined in 301 consecutive patients who were treated with IRT. MACE was defined as death, myocardial infarction, or any reintervention. Long term clinical outcome was obtained from an electronic database of hospital records and from questionnaires to the patients and referring physicians. Long term survival status was assessed by written inquiries to the municipal civil registries. RESULTS: The mean (SD) follow up was 3.6 (1.2) years. The cumulative incidence of MACE at six months was 19.1%, at one year 36.4%, and at four years 58.3%. The target lesion revascularisation (TLR) rate at six months was 12.9%, at one year 28.3%, and at four years 50.4%. From multivariate analysis, dose < 18 Gy was the most significant predictor of TLR. At four years the cumulative incidence of death was 3.8%, of myocardial infarction 13.4%, and of coronary artery bypass surgery 11.3%. Total vessel occlusion was documented in 12.3% of the patients. CONCLUSIONS: In the long term follow up of patients after IRT, there are increased adverse cardiac events beyond the first six months.

One year clinical follow up of paclitaxel eluting stents for acute myocardial infarction compared with sirolimus eluting stents.

OBJECTIVE: To compare clinical outcome of paclitaxel eluting stents (PES) versus sirolimus eluting stents (SES) for the treatment of acute ST elevation myocardial infarction. DESIGN AND PATIENTS: The first 136 consecutive patients treated exclusively with PES in the setting of primary percutaneous coronary intervention for acute myocardial infarction in this single centre registry were prospectively clinically assessed at 30 days and one year. They were compared with 186 consecutive patients treated exclusively with SES in the preceding period. SETTING: Academic tertiary referral centre. RESULTS: At 30 days, the rate of all cause mortality and reinfarction was similar between groups (6.5% v 6.6% for SES and PES, respectively, p = 1.0). A significant difference in target vessel revascularisation (TVR) was seen in favour of SES (1.1% v 5.1% for PES, p = 0.04). This was driven by stent thrombosis (n = 4), especially in the bifurcation stenting (n = 2). At one year, no significant differences were seen between groups, with no late thrombosis and 1.5% in-stent restenosis (needing TVR) in PES versus no reinterventions in SES (p = 0.2). One year survival free of major adverse cardiac events (MACE) was 90.2% for SES and 85% for PES (p = 0.16). CONCLUSIONS: No significant differences were seen in MACE-free survival at one year between SES and PES for the treatment of acute myocardial infarction with very low rates of reintervention for restenosis. Bifurcation stenting in acute myocardial infarction should, if possible, be avoided because of the increased risk of stent thrombosis.