Calcium Scoring Improves Clinical Management in Patients With Low Clinical Likelihood of Coronary Artery Disease.

BACKGROUND: Coronary artery calcium scoring (CACS) improves management of chest pain patients. However, it is unknown whether the benefit of CACS is dependent on the clinical likelihood (CL). OBJECTIVES: This study aims to investigate for which patients CACS has the greatest benefit when added to a CL model. METHODS: Based on data from a clinical database, the CL of obstructive coronary artery disease (CAD) was calculated for 39,837 patients referred for cardiac imaging due to symptoms suggestive of obstructive CAD. Patients were categorized according to the risk factor-weighted (RF-CL) model (very low, ≤5%; low, >5 to ≤15%; moderate >15 to ≤50%; high, >50%). CL was then recalculated incorporating the CACS result (CACS-CL). Reclassification rates and the number needed to test with CACS to reclassify patients were calculated and validated in 3 independent cohorts (n = 9,635). RESULTS: In total, 15,358 (39%) patients were down- or upclassified after including CACS. Reclassification rates were 8%, 75%, 53%, and 30% in the very low, low, moderate, and high RF-CL categories, respectively. Reclassification to very low CACS-CL occurred in 48% of reclassified patients. The number needed to test to reclassify 1 patient from low RF-CL to very low CACS-CL was 2.1 with consistency across age, sex, and cohorts. CACS-CL correlated better to obstructive CAD prevalence than RF-CL. CONCLUSIONS: Added to an RF-CL model for obstructive CAD, CACS identifies more patients unlikely to benefit from further testing. The number needed to test with CACS to reclassify patients depends on the pretest RF-CL and is lowest in patients with low (>5% to ≤15%) likelihood of CAD.

Validity and reliability of seismocardiography for the estimation of cardiorespiratory fitness.

Background: Low cardiorespiratory fitness (ie, peak oxygen consumption [V.O2peak]) is associated with cardiovascular disease and all-cause mortality and is recognized as an important clinical tool in the assessment of patients. Cardiopulmonary exercise test (CPET) is the gold standard procedure for determination of V.O2peak but has methodological challenges as it is time-consuming and requires specialized equipment and trained professionals. Seismofit is a chest-mounted medical device for estimating V.O2peak at rest using seismocardiography. Objective: The purpose of this study was to investigate the validity and reliability of Seismofit V.O2peak estimation in a healthy population. Methods: On 3 separate days, 20 participants (10 women) underwent estimations of V.O2peak with Seismofit (×2) and Polar Fitness Test (PFT) in randomized order and performed a graded CPET on a cycle ergometer with continuous pulmonary gas exchange measurements. Results: Seismofit V.O2peak showed a significant bias of -3.1 ± 2.4 mL·min-1·kg-1 (mean ± 95% confidence interval) and 95% limits of agreement (LoA) of ±10.8 mL·min-1·kg-1 compared to CPET. The mean absolute percentage error (MAPE) was 12.0%. Seismofit V.O2peak had a coefficient of variation of 4.5% ± 1.3% and an intraclass correlation coefficient of 0.95 between test days and a bias of 0.0 ± 0.4 mL·min-1·kg-1 with 95% LoA of ±1.6 mL·min-1·kg-1 in test-retest. In addition, Seismofit showed a 2.4 mL·min-1·kg-1 smaller difference in 95% LoA than PFT compared to CPET. Conclusion: The Seismofit is highly reliable in its estimation of V.O2peak. However, based on the measurement error and MAPE >10%, the Seismofit V.O2peak estimation model needs further improvement to be considered for use in clinical settings.

Coronary Calcium Scoring Improves Risk Prediction in Patients With Suspected Obstructive Coronary Artery Disease.

BACKGROUND: In patients with suspected obstructive coronary artery disease (CAD), the risk factor-weighted clinical likelihood (RF-CL) model and the coronary artery calcium score-weighted clinical likelihood (CACS-CL) model improves the identification of obstructive CAD compared with basic pretest probability (PTP) models. OBJECTIVES: The aim of this study was to assess the prognostic value of the new models. METHODS: The incidences of myocardial infarction and death were stratified according to categories by the RF-CL and CACS-CL and compared with categories by the PTP model. We used cohorts from a Danish register (n = 41,177) and a North American randomized study (n = 3,952). All patients were symptomatic and were referred for diagnostic testing because of clinical indications. RESULTS: Despite substantial down-reclassification of patients to a likelihood ≤5% of CAD with either the RF-CL (45%) or CACS-CL (60%) models compared with the PTP (18%), the annualized event rates of myocardial infarction and death were low using all 3 models; RF-CL 0.51% (95% CI: 0.46-0.56), CACS-CL 0.48% (95% CI: 0.44-0.56), and PTP 0.37% (95% CI: 0.31-0.44), respectively. Overall, comparison of the predictive power of the 3 models using Harrell's C-statistics demonstrated superiority of the RF-CL (0.64 [95% CI: 0.63-0.65]) and CACS-CL (0.69 [95% CI: 0.67-0.70]) compared with the PTP model (0.61 [95% CI: 0.60-0.62]). CONCLUSIONS: The simple clinical likelihood models that include classical risk factors or risk factors combined with CACS provide improved risk stratification for myocardial infarction and death compared with the standard PTP model. Hence, the optimized RF-CL and CACS-CL models identify 2.5 and 3.3 times more patients, respectively, who may not benefit from further diagnostic testing.

Prospective validation of an acoustic-based system for the detection of obstructive coronary artery disease in a high-prevalence population.

Recent guidelines recommend a risk-adjusted, non-invasive work-up in patients presenting with chest discomfort to exclude coronary artery disease (CAD). However, a risk-adjusted diagnostic approach remains challenging in clinical practice. An acoustic detection device for analyzing micro-bruits induced by stenosis-generated turbulence in the coronary circulation has shown potential for ruling out CAD in patients with low-to-intermediate likelihood. We examined the diagnostic value of this acoustic detection system in a high-prevalence cohort. In total, 226 patients scheduled for clinically indicated invasive coronary angiography (ICA) were prospectively enrolled at two centers and examined using a portable, acoustic detection system. The acoustic analysis was performed in double-blinded fashion prior to quantitative ICA and following percutaneous coronary intervention (PCI). An acoustic detection result (CAD score) was obtained in 94% of all patients. The mean baseline CAD score was 41.2 ± 11.9 in patients with obstructive CAD and 33.8 ± 13.4 in patients without obstructive CAD (p < 0.001). ROC analysis revealed an AUC of 0.661 (95% CI 0.584-0.737). Sensitivity was 97.6% (95% confidence interval (CI) 91.5-99.7%), specificity was 14.5% (CI 9.0-21.7%), negative predictive value was 90.5% (CI 69.6-98.8%), and positive predictive value was 41.7% (CI 34.6-49.0%). Following PCI, the mean CAD score decreased from 40.5 ± 11.2 to 38.3 ± 13.7 (p = 0.039). Using an acoustic detection device identified individuals with CAD in a high-prevalence cohort with high sensitivity but relatively low specificity. The negative predictive value was within the predicted range and may be of value for a fast rule-out of obstructive CAD even in a high-prevalence population.

Multichannel seismocardiography: an imaging modality for investigating heart vibrations.

OBJECTIVE: Seismocardiography is the measurement of vibration waves caused by the beating heart with accelerometer(s) placed on the chest. Investigating the nature and the behavior of these vibration waves, by comparing measurements from multiple sites, would help to understand the heart's mechanical contraction activity. APPROACH: Using newly designed multichannel seismocardiogram equipment, it was possible to investigate the vibration waves with 16 three-axis sensors. The equipment performed well with highly precise synchronization rate over 10 min, linear frequency response and high signal quality. The vibration waves were analyzed using the sagittal axis, a single cardiac cycle and focusing on four fiducial points. Two of the fiducial point where the negative and positive peaks associated with aorta valve opening, along with peaks associated with aorta valve closing. MAIN RESULTS: The respective average centers of mass of the four fiducial points in 13 subjects were at (frontal axis: 35 mm, vertical axis: 5 mm), (31, 6), (26, 24), and (4, -2), relative to the Xiphoid Process. Similar patterns among the subjects were identified for the propagation of the waves across the chest for the four fiducial points. SIGNIFICANCE: The multichannel seismocardiogram equipment successfully revealed a general pattern present in chest surface vibration maps.

Author Correction: Definition of Fiducial Points in the Normal Seismocardiogram.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Contractile Fronts In The Interventricular Septum: A Case For High Frame Rate Echocardiographic Imaging.

The real time high frame rate (HFR) 2-dimensional ultrasound system, T5, at Duke University is capable of imaging at up to 1000 images per second for adult cardiac imaging. A method for detecting and visualizing the mechanical contraction fronts using HFR echocardioagraphy-derived Strain Rate Image (SRI) was described in 26 patients. The Tissue Shortening Onset front durations for echocardiographic normal patients were significantly shorter than conduction disorder patients with left bundle branch block (LBBB) with intrinsic conduction and conduction disorder patients without LBBB (non-LBBB) with simulated LBBB (sLBBB). Echocardiographic normal patients had significantly higher correlation coefficients between their SRIs and spatially inverted versions of themselves compared to non-LBBB patients with intrinsic conduction and sLBBB. In conclusion, SRIs could spatially resolve contractile event fronts in patients.

Comparison of Different Methods for Estimating Cardiac Timings: A Comprehensive Multimodal Echocardiography Investigation.

Cardiac time intervals are important hemodynamic indices and provide information about left ventricular performance. Phonocardiography (PCG), impedance cardiography (ICG), and recently, seismocardiography (SCG) have been unobtrusive methods of choice for detection of cardiac time intervals and have potentials to be integrated into wearable devices. The main purpose of this study was to investigate the accuracy and precision of beat-to-beat extraction of cardiac timings from the PCG, ICG and SCG recordings in comparison to multimodal echocardiography (Doppler, TDI, and M-mode) as the gold clinical standard. Recordings were obtained from 86 healthy adults and in total 2,120 cardiac cycles were analyzed. For estimation of the pre-ejection period (PEP), 43% of ICG annotations fell in the corresponding echocardiography ranges while this was 86% for SCG. For estimation of the total systolic time (TST), these numbers were 43, 80, and 90% for ICG, PCG, and SCG, respectively. In summary, SCG and PCG signals provided an acceptable accuracy and precision in estimating cardiac timings, as compared to ICG.

Quantitative Parameters of High-Frame-Rate Strain in Patients with Echocardiographically Normal Function.

Recently, we developed a high-frame-rate echocardiographic imaging system capable of acquiring images at rates up to 2500 per second. High imaging rates were used to quantify longitudinal strain parameters in patients with echocardiographically normal function. These data can serve as a baseline for comparing strain parameters in disease states. The derived timing data also reveal the propagation of mechanical events in the left ventricle throughout the cardiac cycle. High-frame-rate echocardiographic images were acquired from 17 patients in the apical four-chamber view using Duke University's phased array ultrasound system, T5. B-Mode images were acquired at 500-1000 images per second by employing 16:1 or 32:1 parallel processing in receive, a scan depth ≤14 cm and an 80° field of view with a 3.5-MegaHertZ (MHz), 96-element linear array. The images were analyzed using a speckle tracking algorithm tailored for high-frame-rate echocardiographic images developed at Aalborg and Duke University. Four specific mechanical events were defined using strain curves from six regions along the myocardial contour of the left ventricle. The strain curves measure the local deformation events of the myocardium and are independent of the overall cardiac motion. We observed statistically significant differences in the temporal sequence among different myocardial segments for the first mechanical event described, myocardial tissue shortening onset (p < 0.01). We found that the spatial origin of tissue shortening was located near the middle of the interventricular septum in patients with echocardiographically normal function. The quantitative parameters defined here, based on high-speed strain measurements in patients with echocardiographically normal function, can serve as a means of assessing degree of contractile abnormality in the myocardium and enable the identification of contraction propagation. The relative timing pattern among specific events with respect to the Q wave may become an important new metric in assessing cardiac function and may, in turn, improve diagnosis and prognosis.

Definition of Fiducial Points in the Normal Seismocardiogram.

The purpose of this work is to define fiducial points in the seismocardiogram (SCG) and to correlate them with physiological events identified in ultrasound images. For 45 healthy subjects the SCG and the electrocardiogram (ECG) were recorded simultaneously at rest. Immediately following the SCG and ECG recordings ultrasound images of the heart were also obtained at rest. For all subjects a mean SCG signal was calculated and all fiducial points (peaks and valleys) were identified and labeled in the same way across all signals. Eight physiologic events, including the valve openings and closings, were annotated from ultrasound as well and the fiducial points were correlated with those physiologic events. A total of 42 SCG signals were used in the data analysis. The smallest mean differences (±SD) between the eight events found in the ultrasound images and the fiducial points, together with their correlation coefficients (r) were: atrial systolic onset: -2 (±16) ms, r = 0.75 (p < 0.001); peak atrial inflow: 13 (±19) ms, r = 0.63 (p < 0.001); mitral valve closure: 4 (±11) ms, r = 0.71 (p < 0.01); aortic valve opening: -3 (±11) ms, r = 0.60 (p < 0.001); peak systolic inflow: 13 (±23) ms, r = 0.42 (p < 0.01); aortic valve closure: -5 (±12) ms, r = 0.94 (p < 0.001); mitral valve opening: -7 (±19) ms, r = 0.87 (p < 0.001) and peak early ventricular filling: -18 (±28 ms), r = 0.79 (p < 0.001). In conclusion eight physiologic events characterizeing the cardiac cycle, are associated with reproducible, well-defined fiducial points in the SCG.

Separation and characterization of maternal cardiac and vascular sounds in the third trimester of pregnancy.

OBJECTIVE: To characterize the vascular sounds of the uteroplacental blood flow obtained by microphones. METHODS: The present retrospective study took place in an anechoic chamber facility at Aalborg University, Aalborg, Denmark, in 2012, and included pregnant participants aged 18-40 years with a singleton pregnancy at 32-36 weeks and a parity of 0-2. Abdominal Doppler ultrasonography was performed bilaterally on the uterine arteries. Subsequently, in the same positions, sound recordings were performed with microphones. The derived raw sound signal was separated into two frequency ranges, and characterized accordingly. RESULTS: The mean pregnancy length among 25 participants was 33.6 ± 2.0 weeks. The pulsatility index of the uterine artery was 0.67 ± 0.24. All 50 recordings displayed the first and second maternal heart sounds (frequency 25-100 Hz), and in 17 of 50 recordings, maternal vascular murmurs (frequency 200-800 Hz) were present. The average pulse wave velocity between the maternal aortic valve and the uterine artery was estimated to be 6.6 ± 1.5 m/s. CONCLUSION: Maternal vascular murmurs in the frequency range of 200-800 Hz were identified as a possible marker of abnormal uteroplacental blood flow, and provide a means to measure the arterial pulse wave velocity.

An open access database for the evaluation of heart sound algorithms.

In the past few decades, analysis of heart sound signals (i.e. the phonocardiogram or PCG), especially for automated heart sound segmentation and classification, has been widely studied and has been reported to have the potential value to detect pathology accurately in clinical applications. However, comparative analyses of algorithms in the literature have been hindered by the lack of high-quality, rigorously validated, and standardized open databases of heart sound recordings. This paper describes a public heart sound database, assembled for an international competition, the PhysioNet/Computing in Cardiology (CinC) Challenge 2016. The archive comprises nine different heart sound databases sourced from multiple research groups around the world. It includes 2435 heart sound recordings in total collected from 1297 healthy subjects and patients with a variety of conditions, including heart valve disease and coronary artery disease. The recordings were collected from a variety of clinical or nonclinical (such as in-home visits) environments and equipment. The length of recording varied from several seconds to several minutes. This article reports detailed information about the subjects/patients including demographics (number, age, gender), recordings (number, location, state and time length), associated synchronously recorded signals, sampling frequency and sensor type used. We also provide a brief summary of the commonly used heart sound segmentation and classification methods, including open source code provided concurrently for the Challenge. A description of the PhysioNet/CinC Challenge 2016, including the main aims, the training and test sets, the hand corrected annotations for different heart sound states, the scoring mechanism, and associated open source code are provided. In addition, several potential benefits from the public heart sound database are discussed.

High-Frame-Rate Deformation Imaging in Two Dimensions Using Continuous Speckle-Feature Tracking.

The study describes a novel algorithm for deriving myocardial strain from an entire cardiac cycle using high-frame-rate ultrasound images. Validation of the tracking algorithm was conducted in vitro prior to the application to patient images. High-frame-rate ultrasound images were acquired in vivo from 10 patients, and strain curves were derived in six myocardial regions around the left ventricle from the apical four-chamber view. Strain curves derived from high-frame-rate images had a higher frequency content than those derived using conventional methods, reflecting improved temporal sampling.

Acoustic Features for the Identification of Coronary Artery Disease.

GOAL: Earlier studies have documented that coronary artery disease (CAD) produces weak murmurs, which might be detected through analysis of heart sounds. An electronic stethoscope with a digital signal processing unit could be a low cost and easily applied method for diagnosis of CAD. The current study is a search for heart sound features which might identify CAD. METHODS: Nine different types of features from five overlapping frequency bands were obtained and analyzed using 435 recordings from 133 subjects. RESULTS: New features describing an increase in low-frequency power in CAD patients were identified. The features of the different types were relatively strongly correlated. Using a quadratic discriminant function, multiple features were combined into a CAD-score. The area under the receiving operating characteristic for the CAD score was 0.73 (95% CI: 0.69-0.78). CONCLUSION: The result confirms that there is a potential in heart sounds for the diagnosis of CAD, but that further improvements are necessary to gain clinical relevance.