RESUMEN
Background and aims: Currently applied methods for risk-assessment in coronary artery disease (CAD) often overestimate patients' risk for obstructive CAD. To enhance risk estimation, assessment of coronary artery calcium (CAC) can be applied. In 10 % of patients presenting with stable chest pain a previous non-gated computed tomography (CT) has been performed, suitable for CAC-assessment. This study is the first to investigate the clinical utility of CAC-assessment on non-gated CT for risk-assessment of obstructive CAD in symptomatic patients. Methods: For this analysis, all patients referred for coronary computed tomography angiography (CCTA), in whom a previous non-gated chest CT was performed were included. The extent of CAC was assessed on chest CT and ordinally scored. CAD was assessed on CCTA and obstructive CAD defined as stenosis of ≥70 %. Patients were stratified according to CAC-severity and percentages of patients with obstructive CAD were compared between the CAC groups. Results: In total, 170 patients of 32-88 years were included and 35 % were male. The percentage of obstructive CAD between the CAC groups differed significantly (p < 0.01). A calcium score of 0 ruled out obstructive CAD irrespective of sex, pre-test probability, type of complaints and number of risk factors with a 100 % certainty. Furthermore, a mild CAC score ruled out obstructive CAD in patients with low - intermediate PTP or non-anginal complaints with 100 % certainty. Conclusion: When available, CAC on non-gated chest CT can accurately rule out obstructive CAD and can therefore function as a radiation-free and cost-free gatekeeper for additional imaging in patients presenting with stable chest pain.
RESUMEN
BACKGROUND: Guidelines recommend standard pre-operative cardiac screening in all liver transplantation (LT) recipients, despite the relatively low prevalence of obstructive coronary artery disease. Most LT recipients often have non-gated computed tomography (CT) performed of the chest and abdomen. This study evaluated the ability of coronary artery calcification (CAC) assessment on consecutively available scans, to identify a selection of low-risk patients, in whom further cardiac imaging can be safely withheld. METHODS: LT recipients with prior non-gated CT chest-abdomen were included. CAC was visually scored on a semi-quantitative ordinal scale. Stress myocardial perfusion, coronary CT angiography (CCTA) and invasive coronary angiography (ICA) were used as golden standard. The sensitivity and specificity of CAC to exclude and predict obstructive CAD were assessed. In addition, peri- and postoperative mortality and cardiac events were analyzed. RESULTS: 149 LT recipients (ranged 31-71 years) were included. In 75% of patients, no CAC and mild CAC could rule out obstructive CAD on CCTA and ICA with 100% certainty. The threshold of mild CAC had a sensitivity of 100% for both CCTA and ICA and a specificity of 91% and 68%, respectively. None of the patients with no or mild calcifications experienced peri- and post-operative cardiac events or died of cardiac causes. CONCLUSION: Visual evaluation of CAC on prior non-gated CT can accurately and safely exclude obstructive CAD in LT recipients. Incorporation of these already available data can optimize cardiac screening, by safely withholding or correctly allocating dedicated cardiac imaging in LT recipients. Thereby, reducing patients' test burden and save health care expenses.
Asunto(s)
Enfermedad de la Arteria Coronaria , Trasplante de Hígado , Cuidados Preoperatorios , Calcificación Vascular , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Adulto , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Calcificación Vascular/diagnóstico por imagen , Cuidados Preoperatorios/métodos , Cuidados Preoperatorios/normas , Tomografía Computarizada por Rayos X/métodos , Angiografía por Tomografía Computarizada/métodos , Angiografía Coronaria/métodos , Vasos Coronarios/diagnóstico por imagen , Estudios RetrospectivosRESUMEN
To enhance risk stratification in patients suspected of coronary artery disease, the assessment of coronary artery calcium (CAC) could be incorporated, especially when CAC can be readily assessed on previously performed non-gated chest computed tomography (CT). Guidelines recommend reporting on patients' extent of CAC on these non-cardiac directed exams and various studies have shown the diagnostic and prognostic value. However, this method is still little applied, and no current consensus exists in clinical practice. This review aims to point out the clinical utility of different kinds of CAC assessment on non-gated CTs. It demonstrates that these scans indeed represent a merely untapped and underestimated resource for risk stratification in patients with stable chest pain or an increased risk of cardiovascular events. To our knowledge, this is the first review to describe the clinical utility of different kinds of visual CAC evaluation on non-gated unenhanced chest CT. Various methods of CAC assessment on non-gated CT are discussed and compared in terms of diagnostic and prognostic value. Furthermore, the application of these non-gated CT scans in the general practice of cardiology is discussed. The clinical utility of coronary calcium assessed on non-gated chest CT, according to the current literature, is evident. This resource of information for cardiac risk stratification needs no specific requirements for scan protocol, and is radiation-free and cost-free. However, some gaps in research remain. In conclusion, the integration of CAC on non-gated chest CT in general cardiology should be promoted and research on this method should be encouraged.
RESUMEN
BACKGROUND: Thoracic radiotherapy is one of the corner stones of HL treatment, but it is associated with increased risk of cardiovascular events. As HL is often diagnosed at a young age, long-term follow-up including screening for coronary artery disease (CAD) is recommended. OBJECTIVES: This study aims to evaluate the presence of coronary artery calcium score (CACS) in relation to cardiovascular events in HL patients treated with thoracic radiotherapy compared to a non-cancer control group. METHODS: Consecutive HL patients who underwent evaluation for asymptomatic CAD with coronary computed tomography angiography > 10 years after thoracic irradiation were included. The study population consisted of 97 HL patients matched to 97 non-cancer patients on gender, age, cardiovascular risk factors, and statin use. RESULTS: Mean age during CT scan in the HL population was 45.5 ± 9.9 and in the non-cancer population 45.5 ± 10.3 years. CACS was elevated (defined as >0) in 49 (50.5%) HL patients and 30 (30.9%) control patients. HL survivors had an odds ratio of 2.28 [95% CI: 1.22-4.28] for having a CACS > 0 compared to the matched population (p = 0.006). Prevalence of CACS > 90th percentile differed significantly: 17.1% in HL survivors vs. 4.6% in the matched population (p = 0.009). Non-obstructive coronary artery stenosis was more prevalent in the HL population than in the control population (45.7% vs. 28.4%, respectively, p = 0.01). During follow-up of 8.5 [5.3; 9.9] years, nine HL patients experienced an event including two patients with a CACS of zero. No events occurred in the control population. CONCLUSION: In a matched study population, HL survivors have a higher prevalence of a CACS > 0 and an increased risk of cardiovascular events after thoracic irradiation compared to a matched non-cancer control group.
RESUMEN
Influenza infection increases the risk of cardiovascular complications and mortality in patients with heart disease. In patients with coronary artery disease influenza vaccination has been shown to reduce cardiovascular mortality, but high-quality evidence was missing. New trial data from a RCT in patients shortly after myocardial infarction has confirmed the significant reduction of the risk of major adverse cardiovascular events (MACE) and cardiovascular death after influenza vaccination. Also in patients with heart failure the first published RCT in heart failure shows a clinical benefit of influenza vaccination versus placebo during the influenza season, confirming preceding observational studies. Meta-analyses from the study data estimate that after influenza vaccination a risk reduction of MACE of at least 25% is possible in patients with heart disease. The current underutilization of influenza vaccines in heart patients should be addressed because influenza vaccination has proven to be an effective and safe instrument for secondary prevention.
Asunto(s)
Enfermedades Cardiovasculares , Insuficiencia Cardíaca , Vacunas contra la Influenza , Gripe Humana , Infarto del Miocardio , Humanos , Gripe Humana/complicaciones , Gripe Humana/prevención & control , Enfermedades Cardiovasculares/tratamiento farmacológico , Prevención Secundaria , Infarto del Miocardio/complicaciones , Insuficiencia Cardíaca/complicaciones , VacunaciónRESUMEN
Given current pretest probability (PTP) estimations tend to overestimate patients' risk for obstructive coronary artery disease, evaluation of patients' coronary artery calcium (CAC) is more precise. The value of CAC assessment with the Agatston score on cardiac computed tomography (CT) for risk estimation has been well indicated in patients with stable chest pain. CAC can be equally well assessed on routine non-gated chest CT, which is often available. This study aims to determine the clinical applicability of CAC assessment on non-gated CT in patients with stable chest pain compared with the classic Agatston score on gated CT. Consecutive patients referred for evaluation of the Agatston score, who had a previously performed non-gated chest CT for evaluation of noncardiac diseases, were included. CAC on non-gated CT was ordinally scored. Subsequently, patients were stratified according to CAC severity and PTP. The agreement and correlation between the classic Agatston score and CAC on non-gated CT were evaluated. The discriminative power for risk reclassification of both CAC assessment methods was assessed. Invasive coronary angiography was used as the gold standard, when available. A total of 140 patients aged between 30 and 88 years were included. The agreement between ordinally scored CAC and the Agatston score was excellent (κ = 0.82) and the correlation strong (r = 0.94). Most patients (80%) with an intermediate PTP had no or mild CAC on non-gated CT. They were reclassified at low risk with 100% accuracy compared with invasive coronary angiography. Similarly, 86% of patients had an Agatston score <300. These patients were reclassified with 98% accuracy. In patients with high PTP, the accuracy remained substantial and comparable, 94% and 89%, respectively. In conclusion, we believe this is the first study to assess the clinical applicability of CAC on non-gated CT in patients with stable chest pain, compared with the classic Agatston score. The agreement between methods was excellent and the correlation strong. Furthermore, CAC assessment on non-gated CT could reclassify patients' risk for obstructive coronary artery disease as accurately as could the classic Agatston score.
Asunto(s)
Enfermedad de la Arteria Coronaria , Calcificación Vascular , Humanos , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Calcio , Vasos Coronarios/diagnóstico por imagen , Calcificación Vascular/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Angiografía Coronaria/métodos , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/etiología , Angiografía por Tomografía Computarizada , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: The prevalence of coronary artery disease is increasing due to the aging population and increasing prevalence of cardiovascular risk factors. Non-acute chest pain often is the first symptom of stable coronary artery disease. To optimise care for patients with non-acute chest pain and make efficient use of available resources, we need to know more about the current incidence, referral rate and management of these patients. METHODS: We used routinely collected health data from the STIZON data warehouse in the Netherlands between 2010 and 2016. Patients > 18 years, with no history of cardiovascular disease, seen by the general practitioner (GP) for non-acute chest pain with a suspected cardiac origin were included. Outcomes were (i) incidence of new non-acute chest pain in primary care, (ii) referral rates to the cardiologist, (iii) correspondence from the cardiologist to the GP, (iv) registration by GPs of received correspondence and; (v) pharmacological guideline adherence after newly diagnosed stable angina pectoris. RESULTS: In total 9029 patients were included during the study period, resulting in an incidence of new non-acute chest pain of 1.01/1000 patient-years. 2166 (24%) patients were referred to the cardiologist. In 857/2114 (41%) referred patients, correspondence from the cardiologist was not available in the GP's electronic medical record. In 753/1257 (60%) patients with available correspondence, the GP did not code the conclusion in the electronic medical record. Despite guideline recommendations, 37/255 (15%) patients with angina pectoris were not prescribed antiplatelet therapy nor anticoagulation, 69/255 (27%) no statin and 67/255 (26%) no beta-blocker. CONCLUSION: After referral, both communication from cardiologists and registration of the final diagnosis by GPs were suboptimal. Both cardiologists and GPs should make adequate communication and registration a priority, as it improves health outcomes. Secondary pharmacological prevention in patients with angina pectoris was below guideline standards. So, proactive attention needs to be given to optimise secondary prevention in this high-risk group in primary care.
Asunto(s)
Enfermedad de la Arteria Coronaria , Datos de Salud Recolectados Rutinariamente , Humanos , Anciano , Estudios de Cohortes , Adhesión a Directriz , Angina de Pecho/diagnóstico , Angina de Pecho/epidemiología , Derivación y Consulta , Atención Primaria de SaludRESUMEN
Background The performance of current diagnostic algorithms of the American College of Cardiology/American Heart Association (ACC/AHA), National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) in patients with stable chest pain and coronary artery calcium (CAC) remains a matter of debate. We compared their merits in patients with CAC and investigated the additional value of the CAC score to improve diagnostic accuracy and risk stratification. Methods and results Patient data were obtained from a prospective registry of 642 consecutive patients. Mean age 63 (SD 11) years, 50% male. According to the guidelines, low and intermediate/high pre-test probability groups were constructed. Patients were reclassified based on their CAC score. Obstructive coronary artery disease (CAD) was observed in 14%. All models performed modestly in accurately predicting CAD (c-statistic <0.65). After addition of the CAC score, the c-statistic of the NICE model increased to 0.75 (95% confidence interval (CI) 0.73-0.78) which was just non-significant compared to the ESC model (0.71 95% CI 0.67-0.74) and performed significantly better than ACC/AHA (0.68 (95% CI 0.64-0.72)). After reclassification more than 50% of patients were classified low risk in NICE and ESC, while the prevalence of obstructive CAD (4.8% and 5.2% respectively) did not increase. Conclusions Addition of the CAC score to the studied models improved the ability to safely rule-out obstructive CAD and identified other patients at high risk for future coronary artery events. These results suggest that incorporating CAC score will lead to substantially less downstream testing and lower costs.
Asunto(s)
Angina Estable , Enfermedad de la Arteria Coronaria , Angina Estable/diagnóstico por imagen , Angina Estable/epidemiología , Calcio , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Estados UnidosRESUMEN
AIMS: Non-acute chest pain is a common complaint and can be caused by various conditions. With the rising healthcare expenditures of today, it is necessary to use our healthcare resources effectively. This study aims to give insight into the diagnostic effort and costs for patients with non-acute chest pain. METHODS AND RESULTS: Financial data of patients without a cardiac history from four hospitals (January 2012-October 2018), who were registered with the national diagnostic code 'no cardiac pathology' (ICD-10 Z13.6), 'chest wall syndrome' (ICD-10 R07.4), or 'stable angina pectoris' (ICD-10 I20.9) were extracted. In total, 74 091 patients were included for analysis and divided into the following final diagnosis groups: no cardiac pathology: N = 19 688 (age 53 ± 18), 46% male; chest wall syndrome: N = 40 858 (age 56 ± 15), 45% male; and stable angina pectoris (AP): N = 13 545 (age 67 ± 11), 61% male. A total of approximately 142.7 million was spent during diagnostic work-up. The total expenditure during diagnostic effort was 1.97, 8.13, and 10.7 million, respectively for no cardiac pathology, chest wall syndrome, and stable AP per year. After 8 years of follow-up, ≥95% of the patients diagnosed with no cardiac pathology or chest wall syndrome had an (cardiac) ischaemic-free survival. CONCLUSION: The diagnostic expenditure and clinical effort to ascertain non-cardiac chest pain are high. We should define what we as society find acceptable as 'assurance costs' with an increasing pressure on the healthcare system and costs.
Asunto(s)
Angina Estable , Dolor en el Pecho , Adulto , Anciano , Dolor en el Pecho/diagnóstico , Dolor en el Pecho/etiología , Atención a la Salud , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
AIMS: Screening for a high cardiovascular disease (CVD) risk followed by preventive treatment can potentially reduce coronary heart disease-related morbidity and mortality. ROBINSCA (Risk Or Benefit IN Screening for CArdiovascular disease) is a population-based randomized controlled screening trial that investigates the effectiveness of CVD screening in asymptomatic participants using the Systematic COronary Risk Evaluation (SCORE) model or coronary artery calcium (CAC) scoring. This study describes the distributions in risk and treatment in the ROBINSCA trial. METHODS AND RESULTS: Individuals at expected elevated CVD risk were randomized into screening arm A (n = 14 478; SCORE, 10-year fatal and non-fatal risk); or screening arm B (n = 14 450; CAC scoring). Preventive treatment was largely advised according to current Dutch guidelines. Risk and treatment differences between the screening arms were analysed. A total of 12 185 participants (84.2%) in arm A and 12 950 (89.6%) in arm B were screened. In total, 48.7% were women, and median age was 62 (interquartile range 10) years. SCORE screening identified 45.1% at low risk (SCORE < 10%), 26.5% at intermediate risk (SCORE 10-20%), and 28.4% at high risk (SCORE ≥ 20%). According to CAC screening, 76.0% were at low risk (Agatston < 100), 15.1% at high risk (Agatston 100-399), and 8.9% at very high risk (Agatston ≥ 400). CAC scoring significantly reduced the number of individuals indicated for preventive treatment compared to SCORE (relative reduction women: 37.2%; men: 28.8%). CONCLUSION: We showed that compared to risk stratification based on SCORE, CAC scoring classified significantly fewer men and women at increased risk, and less preventive treatment was indicated. TRIAL REGISTRATION NUMBER: NTR6471.
Asunto(s)
Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Calcificación Vascular , Calcio , Enfermedades Cardiovasculares/diagnóstico por imagen , Enfermedades Cardiovasculares/epidemiología , Niño , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Masculino , Medición de Riesgo , Factores de Riesgo , Tomografía Computarizada por Rayos X , Calcificación Vascular/diagnóstico por imagenRESUMEN
Physicians may not be familiar with caseous calcification of the mitral annulus. It can therefore easily be mistaken for other conditions including tumors. In the appropriate clinical context, by using multimodality imaging, a correct diagnosis can be made, and patient concern or even unnecessary surgery can be avoided.
RESUMEN
OBJECTIVES: This study assessed whether adenosine stress-only perfusion cardiac magnetic resonance (CMR) following a positive coronary artery calcium (CAC) score improved the diagnostic yield of invasive coronary angiography (CAG) in patients with stable chest pain. The study also established the association between positive CAC scores and stress-induced myocardial ischemia. BACKGROUND: The diagnostic yield of catheterization among patients with suspected coronary artery disease (CAD) is low. Improved patient selection and diagnostic testing are necessary. The CAC score can minimize unnecessary diagnostic testing, and in low-risk patients, normal CMR results have a high negative predictive value. Less comprehensive protocols may be sufï¬cient to guide further work-up. METHODS: A total of 642 consecutive patients (mean age: 63 years; 50% women) with stable chest pain and CAC scores of >0 who were referred for CMR were enrolled. Patients with a perfusion defect were subsequently examined by CAG. Patients were followed up for 1 year. Outcome was obstructive CAD. RESULTS: Obstructive CAD was present in 12% of patients. For CAD diagnosis, the sensitivity of adenosine CMR was 90.9% (95% confidence interval [CI]: 88.7 to 93.1), specificity was 98.7% (95% CI: 97.9 to 99.6), positive predictive value was 92.0% (95% CI: 89.8 to 94.1), and negative predictive value was 98.6% (95% CI: 97.6 to 99.5). A CAC score between 0.1 and 100 without typical angina was associated with obstructive CAD in only 3% of patients. Patients with nonanginal chest pain and a CAC score ≥400 had obstructive CAD (16%). CONCLUSIONS: Stress-only adenosine CMR had high diagnostic accuracy and served as an efficient gatekeeper to CAG in stable patients with a CAC score >0. Patients with CAC scores between 0.1 and 100 could be deferred from further testing in the absence of clinical features that suggested high risk. However, in patients with CAC score ≥400, functional testing should be indicated, regardless of the type of chest pain.
Asunto(s)
Adenosina/administración & dosificación , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Imagen por Resonancia Magnética , Tomografía Computarizada Multidetector , Imagen de Perfusión Miocárdica , Calcificación Vascular/diagnóstico por imagen , Vasodilatadores/administración & dosificación , Anciano , Enfermedad de la Arteria Coronaria/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sistema de Registros , Reproducibilidad de los Resultados , Calcificación Vascular/terapiaRESUMEN
BACKGROUND: Guidelines advise periprocedural saline hydration for prevention of contrast induced-acute kidney injury (CI-AKI). We analysed whether 1-hour sodium bicarbonate hydration administered solely prior to intra-arterial contrast exposure is non-inferior to standard periprocedural saline hydration in chronic kidney disease (CKD) patients undergoing elective cardiovascular diagnostic or interventional contrast procedures. METHODS: We performed an open-label multicentre non-inferiority trial between 2011-2014. Patients were randomized to 1 hour pre-procedure sodium bicarbonate hydration (250 ml 1.4%, N = 168) or 4-12 hours saline hydration (1000 ml 0.9%, N = 165) prior to and following contrast administration (2000 ml of saline total). Primary outcome was the relative serum creatinine increase (%) 48-96 hours post contrast exposure. Secondary outcomes were: incidence of CI-AKI (serum creatinine increase>25% or >44µmol/L), recovery of renal function, the need for dialysis, and hospital costs within two months follow-up. RESULTS: Mean relative creatinine increase was 3.1% (95%CI 0.9 to 5.2%) in the bicarbonate and 1.1% (95%CI -1.2 to 3.5%) in the saline arm, mean difference 1.9% (95%CI -1.2 to 5.1%, p-non-inferiority <0.001). CI-AKI occurred in 11 (6.7%) patients randomized to sodium bicarbonate and 12 (7.5%) to saline (p = 0.79). Renal function did not fully recover in 40.0% and 44.4% of CI-AKI patients, respectively (p = 0.84). No patient required dialysis. Mean costs for preventive hydration and clinical preparation for the contrast procedure were $1158 for sodium bicarbonate vs. $1561 for saline (p < 0.001). CONCLUSION: Short hydration with sodium bicarbonate prior to elective cardiovascular diagnostic or therapeutic contrast procedures is non-inferior to standard periprocedural saline hydration in CKD patients with respect to renal safety and results in considerable healthcare savings. TRIAL REGISTRATION: Netherlands Trial Register (http://www.trialregister.nl/trialreg/index.asp), Nr NTR2699.
Asunto(s)
Lesión Renal Aguda/prevención & control , Sistema Cardiovascular/diagnóstico por imagen , Medios de Contraste/efectos adversos , Fallo Renal Crónico/terapia , Bicarbonato de Sodio/administración & dosificación , Cloruro de Sodio/administración & dosificación , Lesión Renal Aguda/inducido químicamente , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: Early synthetic gadolinium enhancement (ESGE) imaging from post-contrast T1 mapping after adenosine stress-perfusion cardiac magnetic resonance (CMR) was compared to conventional late gadolinium enhancement (LGE) imaging for assessing myocardial scar. METHODS: Two hundred fourteen consecutive patients suspected of myocardial ischaemia were referred for stress-perfusion CMR. Myocardial infarct volume was quantified on a per-subsegment basis in both synthetic (2-3 min post-gadolinium) and conventional (9 min post-gadolinium) images by two independent observers. Sensitivity, specificity, PPV and NPV were calculated on a per-patient and per-subsegment basis. RESULTS: Both techniques detected 39 gadolinium enhancement areas in 23 patients. The median amount of scar was 2.0 (1.0-3.1) g in ESGE imaging and 2.2 (1.1-3.1) g in LGE imaging (p=0.39). Excellent correlation (r=0.997) and agreement (mean absolute difference: -0.028±0.289 ml) were found between ESGE and LGE images. Sensitivity, specificity, PPV and NPV of ESGE imaging were 96 (78.9-99.9), 99 (97.1-100.0)%, 96 (76.5-99.4) and 99.5 (96.6-99.9) in patient-based and 99 (94.5-100.0), 100 (99.9-100.0)%, 97.0 (91.3-99.0) and 100.0 (99.8-100.0) in subsegment-based analysis. CONCLUSION: ESGE based on post-contrast T1 mapping after adenosine stress-perfusion CMR imaging shows excellent agreement with conventional LGE imaging for assessing myocardial scar, and can substantially shorten clinical acquisition time. KEY POINTS: ⢠Synthetic gadolinium enhancement images can be used for detection of myocardial scar. ⢠Early synthetic gadolinium enhancement images can substantially shorten clinical acquisition time. ⢠ESGE has high diagnostic accuracy as compared to conventional late gadolinium enhancement. ⢠Quantification of myocardial scar with ESGE closely correlates with conventional LGE. ⢠ESGE after stress perfusion CMR avoids need for additional gadolinium administration.
Asunto(s)
Cicatriz/diagnóstico por imagen , Cicatriz/patología , Medios de Contraste , Gadolinio , Angiografía por Resonancia Magnética/métodos , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/patología , Adenosina/administración & dosificación , Anciano , Femenino , Humanos , Aumento de la Imagen , Masculino , Persona de Mediana Edad , Miocardio/patología , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
Caffeine is an adenosine receptor antagonist and a possible cause of inadequate stress perfusion. Splenic switch-off (SSO) and splenic rest-stress T1-mapping have been proposed as indicators of stress adequacy during perfusion cardiac magnetic resonance (CMR). We compared myocardial rest-stress T1-mapping with SSO and splenic rest-stress T1-mapping in patients with and without recent coffee intake. We analyzed 344 consecutive patients suspected of myocardial ischemia with adenosine perfusion CMR. All 146 normal CMR studies with a normal T1-rest of the myocardium, used as standard of reference, were included and divided in two groups. 22 patients accidentally ingested coffee < 4 h before CMR, compared to control group of 124 patients without self-reported coffee intake. Two independent readers graded SSO visually. T1-reactivity (ΔT1) was defined as percentual difference in T1-rest and T1-stress. Follow-up data were extracted from electronic patients records. In patients with recent coffee intake SSO was identified in 96%, which showed no significant difference with SSO in controls (94%, p = 0.835), however event rates were significantly different (13.6 and 0.8%, respectively (p < 0.001), median FU 17 months). Myocardial ΔT1 in the coffee group (- 5.2%) was significantly lower compared to control (+ 4.0%, p < 0.001), in contrast to the splenic ΔT1 (- 3.7 and - 4.0%, p = 0.789). The splenic T1-mapping results failed to predict false negative results. SSO and splenic rest-stress T1-mapping are not reliable indicators of stress adequacy in patients with recent coffee intake. Therefore, the dark spleen sign does not indicate adequate myocardial stress in patients with recent caffeine intake. Myocardial rest-stress T1-mapping is an excellent indicator of stress adequacy during adenosine perfusion CMR.
Asunto(s)
Adenosina/administración & dosificación , Cafeína/efectos adversos , Café/efectos adversos , Circulación Coronaria/efectos de los fármacos , Hemodinámica/efectos de los fármacos , Isquemia Miocárdica/diagnóstico por imagen , Imagen de Perfusión Miocárdica/métodos , Antagonistas de Receptores Purinérgicos P1/efectos adversos , Bazo/irrigación sanguínea , Vasodilatadores/administración & dosificación , Anciano , Cafeína/administración & dosificación , Estudios de Casos y Controles , Femenino , Humanos , Estimación de Kaplan-Meier , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/fisiopatología , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Antagonistas de Receptores Purinérgicos P1/administración & dosificación , Reproducibilidad de los ResultadosRESUMEN
Caffeine intake before adenosine stress myocardial perfusion imaging may cause false negative findings. We hypothesized that the antagonistic effect of caffeine can be measured by T1 relaxation times in rest and adenosine stress cardiac magnetic resonance imaging (CMR), as T1 mapping techniques are sensitive to changes in myocardial blood volume. We prospectively analyzed 105 consecutive patients with adenosine stress perfusion CMR on a 1.5-T MRI system. Rest and stress T1 mapping was performed using Modified Look-Locker Inversion recovery. T1 reactivity was defined as difference in T1rest and T1stress (∆T1). Fifteen patients drank coffee within 4 h of CMR (<4H caffeine group), and 10 patients had coffee the day before (>8H caffeine group). Comparison was made to patients without self-reported coffee intake: 50 with normal CMR (control group), 18 with myocardial ischemia, and 12 with myocardial infarction. The national review board approved the study; all patients gave written informed consent. The <4H caffeine group showed inverted ∆T1 of -7.8 % (T1rest 975 ± 42 ms, T1stress 898 ± 51 ms, p < 0.0005). The >8H caffeine group showed reduced T1 reactivity (1.8 %; T1rest 979 ms, T1stress 997 ms) compared to the controls (4.3 %; T1rest 977 ± 40 ms, T1stress 1018 ± 40 ms), p < 0.0005. Ischemic and infarcted myocardium showed minimal T1 reactivity (0.2 and 0.3 %, respectively). Caffeine intake inverts the adenosine effect during stress perfusion CMR as measured by T1 mapping. T1 reactivity can assess the adequacy of adenosine-induced stress in perfusion CMR.
Asunto(s)
Adenosina/administración & dosificación , Cafeína/administración & dosificación , Café , Circulación Coronaria/efectos de los fármacos , Imagen por Resonancia Magnética , Isquemia Miocárdica/diagnóstico por imagen , Imagen de Perfusión Miocárdica/métodos , Vasodilatadores/administración & dosificación , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Reacciones Falso Negativas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/fisiopatología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
Two male patients aged 57 and 73 were referred to the cardiologist because of progressive dyspnoea. In one patient, the general practitioner had previously adopted an expectative policy because of a clean chest X-ray. At presentation after 4 weeks, the patient was diagnosed with and treated for acute coronary syndrome because of minor ECG abnormalities. Additional CT scanning showed a large saddle embolus. Despite adequate treatment, the patient suffered an electrical asystole and died. The other patient underwent ECG, bicycle ergometry, MRI adenosine, echocardiography and lung function tests over a period of 5 weeks before pulmonary embolism (PE) was diagnosed. As the signs and symptoms of PE are largely non-specific, diagnostic delay is common, with risk of poor clinical outcome. PE should at least be considered whenever a patient presents with acute or worsening breathlessness, chest pain, circulatory collapse or coughing, particularly in the presence of known thrombotic risk factors or when there is no clear alternative.
Asunto(s)
Disnea/etiología , Embolia Pulmonar/diagnóstico , Anciano , Diagnóstico Diferencial , Electrocardiografía , Humanos , Masculino , Persona de Mediana Edad , Arteria Pulmonar/patología , Factores de RiesgoRESUMEN
To assess the diagnostic value of adenosine "stress-only" myocardial perfusion MR for ischemia detection as an indicator for coronary angiography in patients without a prior myocardial infarction and a necessity to exclude ischemia. Adenosine perfusion MRI was performed at 1.5 T in 139 patients with a suspicion of ischemia and no prior myocardial infarction. After 3 min of adenosine infusion a perfusion sequence was started. Patients with a perfusion defect were referred to coronary angiography (CAG). Patients with a normal perfusion were enrolled in follow-up. Fourteen out of 139 patients (10.1%) had a perfusion defect indicative of ischemia. These patients underwent a coronary angiogram, which showed complete agreement with the perfusion images. 125 patients with a normal myocardial perfusion entered follow-up (median 672 days, range 333-1287 days). In the first year of follow-up one Major Adverse Coronary Event (MACE) occurred and one patient had new onset chest pain with a confirmed coronary stenosis. Reaching a negative predictive value for MACE of 99.2% and for any coronary event of 98.4%. At 2 year follow-up no additional MACE occurred. Sensitivity of adenosine perfusion MR for MACE is 93.3% and specificity and positive predictive value are 100%. Adenosine myocardial perfusion MR for the detection of myocardial ischemia in a "stress-only" protocol in patients without prior myocardial infarctions, has a high diagnostic accuracy. This fast examination can play an important role in the evaluation of patients without prior myocardial infarctions and a necessity to exclude ischemia.