Addition of FFRct in the diagnostic pathway of patients with stable chest pain to reduce unnecessary invasive coronary angiography (FUSION) : Rationale and design for the multicentre, randomised, controlled FUSION trial.

BACKGROUND: Coronary computed tomography angiography (CCTA) is widely used in the diagnostic work-up of patients with stable chest pain. CCTA has an excellent negative predictive value, but a moderate positive predictive value for detecting coronary stenosis. Computed tomography-derived fractional flow reserve (FFRct) is a non-invasive, well-validated technique that provides functional assessment of coronary stenosis, improving the positive predictive value of CCTA. However, to determine the value of FFRct in routine clinical practice, a pragmatic randomised, controlled trial (RCT) is required. We will conduct an RCT to investigate the impact of adding FFRct analysis in the diagnostic pathway of patients with a coronary stenosis on CCTA on the rate of unnecessary invasive coronary angiography, cost-effectiveness, quality of life and clinical outcome. METHODS: The FUSION trial is a prospective, multicentre RCT that will randomise 528 patients with stable chest pain and anatomical stenosis of ≥ 50% but < 90% in at least one coronary artery of ≥ 2 mm on CCTA, to FFRct-guided care or usual care in a 1:1 ratio. Follow-up will be 1 year. The primary endpoint is the rate of unnecessary invasive coronary angiography within 90 days. CONCLUSION: The FUSION trial will evaluate the use of FFRct in stable chest pain patients from the Dutch perspective. The trial is funded by the Dutch National Health Care Institute as part of the research programme 'Potentially Promising Care' and the results will be used to assess if FFRct reimbursement should be included in the standard health care package.

Clinical characteristics, cardiac events and coronary angiographic findings in the prospective PREVEND cohort: an observational study.

BACKGROUND: The use of invasive procedures has mostly been studied in retrospective (multi)- national registries. Limited evidence exists on the association between microalbuminuria and coronary artery disease (CAD). METHODS: The incidence of major adverse cardiac events (MACE) and invasive cardiac procedures was registered between 1997 and 2003 in 8139 subjects, without prior documented CAD, in the PREVEND cohort study (the Netherlands), in which the focus is on microalbuminuria and cardiovascular risk. Qualitative coronary angiographic analysis was performed. RESULTS: During 5.5 years of follow-up, a first MACE occurred in 271 (3.3%) and a first coronary angiography (CAG) was performed in 264 (3.2%) subjects. Of these, 216 CAGs were available for qualitative angiographic analysis. Indications for CAG were stable angina in 129, acute coronary syndrome (ACS) in 55 and ST-elevation myocardial infarction (STEMI) in 32 subjects. Obstructive coronary artery disease was present in 61, 53 and 30 subjects, respectively. A revascularisation was performed in 50 (39%), 50 (91%) and 25 (78%) subjects, respectively. Microalbuminuria was associated with a first MACE, after adjustment for established risk factors. Microalbuminuria was present at baseline in 9% of subjects with normal coronary arteries, in 21% of subjects with one- and two-vessel CAD and in 39% of subjects with threevessel or left main CAD at CAG during follow-up (Ptrend=0.005). CONCLUSION: This large cohort study shows that two-thirds of diagnostic CAGs for stable angina were not followed by a revascularisation, in contrast to CAGs for STEMI or ACS. Furthermore, this study shows that microalbuminuria is associated with CAD. (Neth Heart J 2007;15:133-41.).

Coronary risk factors and metabolic disorders in first-degree relatives of normocholesterolaemic patients with premature atherosclerosis.

AIMS: Despite agreement on the need for screening for the presence of cardiovascular risk factors in first-degree family members of patients with premature coronary artery disease (CAD), this is not routinely carried out in relatives of normocholesterolaemic patients. We evaluated cardiovascular risk factors in family members of normocholesterolaemic patients with premature CAD. METHODS: Eligible index subjects were patients with premature CAD (<55 years in men and <65 years in women), who had undergone percutaneous transluminal coronary angioplasty. Patients with fasting total cholesterol levels >6.5 mmol/l were excluded. Sixteen index subjects were included with a mean age of 49±8 years and total cholesterol levels of 5.5±0.8 mmol/l. Sixty-four first-degree relatives from these 16 pedigrees were screened, namely 18 children, 42 siblings and four parents. National Cholesterol Education Program III guidelines were used to identify candidates for lipid-lowering treatment. Furthermore, the presence of four additional metabolic disorders was investigated: the metabolic syndrome, increased levels of lipoprotein(a) (Lp(a)), hyperhomocysteinaemia and postprandial hyperlipidaemia. RESULTS: Of 64 relatives free of CAD, 34 subjects (53%) fulfilled the criteria to receive therapeutic advice, 20 of whom (31% of the relatives) were candidates for drug therapy. Sixty-one relatives were available for a full assessment of metabolic disorders and in 37 relatives (61%) at least one metabolic abnormality was present. Twelve subjects had hyper-Lp(a), seven subjects had postprandial hyperlipidaemia and two had the metabolic syndrome. Furthermore, 16 subjects had a combination of at least two out of four metabolic disorders. CONCLUSION: Careful evaluation of coronary risk factors and metabolic variables in first-degree relatives of normocholesterolaemic CAD patients identifies a significant number of subjects at increased coronary risk in whom primary prevention measures should be initiated.

Magnetic resonance imaging in acute myocarditis: a case report and a review of literature.

We report a case of acute myocarditis in a 20-year-old male, suggested by the clinical picture, elevated cardiac enzymes, electrocardiography and serology. Diagnosis was confirmed by gadolinium-enhanced MRI showing part of the myocardium affected by an infiltrate. Impaired LV function and wall motion abnormalities were documented by echocardiography and FFE MRI. The patient recovered well within two weeks, but will be followed intensively since dilated cardiomyopathy may ensue.

Novel ways to noninvasively detect inflammation of the myocardium: contrast-enhanced MRI and myocardial contrast echocardiography.

Both contrast-enhanced magnetic resonance imaging (CE-MRI) and myocardial contrast echocardiography (MCE) are promising tools to detect cardiac inflammation. CE-MRI can be used to characterise the location and extent of myocardial inflammation, since areas of abnormal signal enhancement associated with regional wall motion abnormalities reliably indicate areas of active myocarditis. In MCE, chemically composed microbubbles can be visualised by ultrasound and used to determine the status of the cardiac microvasculature. If there is any inflammation the microbubbles will be phagocytosed by neutrophils and monocytes, thus enabling the degree of inflammation to be assessed. These noninvasive techniques may allow early diagnosis and accurate evaluation of myocardial inflammation.

Multidetector computed tomography-guided treatment strategy in patients with non-ST elevation acute coronary syndromes: a pilot study.

Patients with non-ST elevation acute coronary syndrome (ACS) and evidence of myocardial ischaemia are scheduled for coronary angiography (CAG). In most patients CAG remains a single diagnostic procedure only. A prospective study was performed to evaluate whether 16-slice multidetector CT (MDCT) could predict treatment of the patients and to determine how many CAGs could have been prevented by MDCT scanning prior to CAG. Twenty-two patients with ACS were scanned prior to CAG. Based on MDCT data, a fictive treatment was proposed and compared to CAG-based treatment. Excellent accuracy was observed to detect significant stenoses using MDCT (sensitivity 94%, specificity 96%). In 45%, no PCI was performed during CAG, because of the absence of significant coronary artery disease (27%) or severe coronary artery disease, demanding CABG (18%). MDCT predicted correct treatment in 86%. By using MDCT data, 32% of the CAGs could have been prevented.