Coronary microvascular function in male physicians with burnout and job stress: an observational study.

BACKGROUND: As a professional group, physicians are at increased risk of burnout and job stress, both of which are associated with an increased risk of coronary heart disease that is at least as high as that of other professionals. This study aimed to examine the association of burnout and job stress with coronary microvascular function, a predictor of major adverse cardiovascular events. METHODS: Thirty male physicians with clinical burnout and 30 controls without burnout were included. Burnout was assessed with the Maslach Burnout Inventory and job stress with the effort-reward imbalance and overcommitment questionnaire. All participants underwent myocardial perfusion positron emission tomography to quantify endothelium-dependent (cold pressor test) and endothelium-independent (adenosine challenge) coronary microvascular function. Burnout and job stress were regressed on coronary flow reserve (primary outcome) and two additional measures of coronary microvascular function in the same model while adjusting for age and body mass index. RESULTS: Burnout and job stress were significantly and independently associated with endothelium-dependent microvascular function. Burnout was positively associated with coronary flow reserve, myocardial blood flow response, and hyperemic myocardial blood flow (r partial = 0.28 to 0.35; p-value = 0.008 to 0.035). Effort-reward ratio (r partial = - 0.32 to - 0.38; p-value = 0.004 to 0.015) and overcommitment (r partial = - 0.30 to - 0.37; p-value = 0.005 to 0.022) showed inverse associations with these measures. CONCLUSIONS: In male physicians, burnout and high job stress showed opposite associations with coronary microvascular endothelial function. Longitudinal studies are needed to show potential clinical implications and temporal relationships between work-related variables and coronary microvascular function. Future studies should include burnout and job stress for a more nuanced understanding of their potential role in cardiovascular health.

Radiomics for the detection of diffusely impaired myocardial perfusion: A proof-of-concept study using 13N-ammonia positron emission tomography.

AIM: The current proof-of-concept study investigates the value of radiomic features from normal 13N-ammonia positron emission tomography (PET) myocardial retention images to identify patients with reduced global myocardial flow reserve (MFR). METHODS: Data from 100 patients with normal retention 13N-ammonia PET scans were divided into two groups, according to global MFR (i.e., < 2 and ≥ 2), as derived from quantitative PET analysis. We extracted radiomic features from retention images at each of five different gray-level (GL) discretization (8, 16, 32, 64, and 128 bins). Outcome independent and dependent feature selection and subsequent univariate and multivariate analyses was performed to identify image features predicting reduced global MFR. RESULTS: A total of 475 radiomic features were extracted per patient. Outcome independent and dependent feature selection resulted in a remainder of 35 features. Discretization at 16 bins (GL16) yielded the highest number of significant predictors of reduced MFR and was chosen for the final analysis. GLRLM_GLNU was the most robust parameter and at a cut-off of 948 yielded an accuracy, sensitivity, specificity, negative and positive predictive value of 67%, 74%, 58%, 64%, and 69%, respectively, to detect diffusely impaired myocardial perfusion. CONCLUSION: A single radiomic feature (GLRLM_GLNU) extracted from visually normal 13N-ammonia PET retention images independently predicts reduced global MFR with moderate accuracy. This concept could potentially be applied to other myocardial perfusion imaging modalities based purely on relative distribution patterns to allow for better detection of diffuse disease.

High-Speed On-Site Deep Learning-Based FFR-CT Algorithm: Evaluation Using Invasive Angiography as the Reference Standard.

BACKGROUND. Estimation of fractional flow reserve from coronary CTA (FFR-CT) is an established method of assessing the hemodynamic significance of coronary lesions. However, clinical implementation has progressed slowly, partly because of off-site data transfer with long turnaround times for results. OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance of FFR-CT computed on-site with a high-speed deep learning-based algorithm with invasive hemodynamic indexes as the reference standard. METHODS. This retrospective study included 59 patients (46 men, 13 women; mean age, 66.5 ± 10.2 years) who underwent coronary CTA (including calcium scoring) followed within 90 days by invasive angiography with invasive fractional flow reserve (FFR) and/or instantaneous wave-free ratio measurements from December 2014 to October 2021. Coronary artery lesions were considered to have hemodynamically significant stenosis in the presence of invasive FFR of 0.80 or less and/or instantaneous wave-free ratio of 0.89 or less. A single cardiologist evaluated the CTA images using an on-site deep learning-based semiautomated algorithm entailing a 3D computational flow dynamics model to determine FFR-CT for coronary artery lesions detected with invasive angiography. Time for FFR-CT analysis was recorded. FFR-CT analysis was repeated by the same cardiologist in 26 randomly selected examinations and by a different cardiologist in 45 randomly selected examinations. Diagnostic performance and agreement were assessed. RESULTS. A total of 74 lesions were identified with invasive angiography. FFR-CT and invasive FFR had strong correlation (r = 0.81) and, in Bland-Altman analysis, bias of 0.01 and 95% limits of agreement of -0.13 to 0.15. FFR-CT had AUC for hemodynamically significant stenosis of 0.975. At a cutoff of 0.80 or less, FFR-CT had 95.9% accuracy, 93.5% sensitivity, and 97.7% specificity. In 39 lesions with severe calcifications (≥ 400 Agatston units), FFR-CT had AUC of 0.991 and at a cutoff of 0.80, 94.7% sensitivity, 95.0% specificity, and 94.9% accuracy. Mean analysis time per patient was 7 minutes 54 seconds. Intraobserver agreement (intraclass correlation coefficient, 0.85; bias, -0.01; 95% limits of agreement, -0.12 and 0.10) and interobserver agreement (intraclass correlation coefficient, 0.94; bias, -0.01; 95% limits of agreement, -0.08 and 0.07) were good to excellent. CONCLUSION. A high-speed on-site deep learning-based FFR-CT algorithm had excellent diagnostic performance for hemodynamically significant stenosis with high reproducibility. CLINICAL IMPACT. The algorithm should facilitate implementation of FFR-CT technology into routine clinical practice.

Prognostic Implications of Clinical and Imaging Diagnostic Criteria for Myocarditis.

BACKGROUND: The European Society of Cardiology (ESC), the American College of Cardiology, the American Heart Association, and expert consensus documents provide different diagnostic criteria for myocarditis. Their overlap and prognostic value have never been compared. OBJECTIVES: This study aims to assess and compare the predictive value of ESC criteria for clinically suspected myocarditis, updated Lake-Louise criteria (LLC), American Heart Association criteria for probable acute myocarditis (pAM), and expert consensus criteria for acute myocarditis (AM) and complicated myocarditis (CM). METHODS: Patients with a clinical suspicion of myocarditis referred for cardiac magnetic resonance were enrolled at 2 centers. Those with any prior cardiomyopathy were excluded. The association of composite outcome events (heart failure hospitalization, recurrent myocarditis, sustained ventricular tachycardia, or death) with ESC diagnostic criteria, LLC, pAM, AM, and CM were compared. RESULTS: Among 1,557 consecutive patients referred for cardiac magnetic resonance with possible myocarditis, 1,050 (62.6% male; 48.9 ± 16.8 years of age) were without an alternative diagnosis. Of those, 938 (89.3%) met ESC criteria for clinically suspected myocarditis, 299 (28.5%) LLC, and 356 (33.9%), 216 (20.6%), and 77 (7.3%) pAM, AM, and CM, respectively. Adverse events occurred in 161 patients (15.3%) during a median follow-up of 3.4 years. The highest annualized event rates (6.6%) were observed in patients meeting LLC, whereas negative ESC criteria indicated excellent prognosis (0.7% annualized event rate). Among all myocarditis definitions, ESC criteria and LLC were the strongest multivariable outcome predictors and had independent and incremental prognostic value (HRadjusted: 3.87; 95% CI: 1.22-12.2; P = 0.021, and HRadjusted: 2.53; 95% CI: 1.83-3.49; P < 0.001, respectively) when adjusted for clinical characteristics. CONCLUSIONS: In a real-world cohort of patients with possible myocarditis, diagnosis was reached in most patients using ESC criteria whereas only approximately one-quarter of patients reached a diagnosis with LLC. The independent prognostic value of ESC-criteria and LLC highlights the complementary role of clinical and CMR-based findings in the diagnosis and risk stratification of myocarditis.

Duration of adenosine-induced myocardial hyperaemia: insights from quantitative 13N-ammonia positron emission tomography myocardial perfusion imaging.

AIMS: This study aimed to assess the impact of adenosine on quantitative myocardial blood flow (MBF) in a rapid stress-rest protocol compared with a rest-stress protocol using 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging (MPI) and to gain insights into the time dependency of such effects. METHODS AND RESULTS: Quantitative MBF at rest (rMBF) and during adenosine-induced stress (sMBF) and myocardial flow reserve (MFR) were obtained from 331 retrospectively identified patients who underwent 13N-ammonia PET MPI for suspected chronic coronary syndrome and who all exhibited no perfusion defects. Of these, 146 (44.1%) underwent a rapid stress-rest protocol with a time interval (Δtstress-rest) of 20 ± 4 min between adenosine infusion offset and rest imaging, as per clinical routine. The remaining 185 (55.9%) patients underwent a rest-stress protocol and served as the reference. Groups did not differ regarding demographics, risk factors, medication, left ventricular function, and calcium scores. rMBF was significantly higher in the stress-rest vs. the rest-stress group [0.80 (interquartile range 0.66-1.00) vs. 0.70 (0.58-0.83) mL·min-1·g-1, P < 0.001], and, as sMBF was identical between groups [2.52 (2.20-2.96) vs. 2.50 (1.96-3.11), P = 0.347], MFR was significantly lower in the stress-rest group [3.07 (2.43-3.88) vs. 3.50 (2.63-4.10), P = 0.007]. There was a weak correlation between Δtstress-rest and rMBF (r = -0.259, P = 0.002) and between Δtstress-rest and MFR (r = 0.163, P = 0.049), and the proportion of patients with abnormally high rMBF was significantly decreasing with increasing Δtstress-rest. CONCLUSION: Intravenously applied adenosine induces a long-lasting hyperaemic effect on the myocardium. Consequently, rapid stress-rest protocols could lead to an overestimation of rMBF and an underestimation of MFR.