The Value of a Coronary Computed Tomography Angiography plus Stress Cardiac Magnetic Resonance Imaging Strategy for the Evaluation of Patients with Chronic Coronary Syndrome.

Background: Noninvasive imaging methods, either anatomical or functional tests, serve as essential instruments for the appropriate management of patients with established or suspected coronary artery disease (CAD). We sought to evaluate the safety and efficacy of a coronary computed tomography angiography (CCTA) plus stress cardiac magnetic resonance imaging (S-CMR) strategy in patients with chronic coronary syndrome (CCS). Methods: Patients with suspected CCS showing intermediate coronary plaques (stenosis 30-70%) at CCTA underwent S-CMR. Patients with a positive S-CMR were referred to invasive coronary angiography (ICA) plus instantaneous wave-free ratio (iFR), and myocardial revascularization if recommended. All patients received guideline-directed medical therapy (GDMT), including high-dose statins, regardless of myocardial revascularization. The primary endpoint was a composite of death from cardiovascular causes, non-fatal myocardial infarction, and unplanned revascularization. Results: According to the results of CCTA, 62 patients showing intermediate coronary plaques underwent S-CMR, which was positive for a myocardial perfusion deficit in n = 17 (27%) and negative in n = 45 (73%) patients. According to the results of ICA plus iFR, revascularization was performed in 13 patients. No differences in the primary endpoint between the positive and negative S-CMR groups were observed at 1 year (1 [5.9%] vs. 1 [2.2%], p = 0.485) and after a median of 33.4 months (2 [11.8%] vs. 3 [6.7%]; p = 0.605). Conclusions: Our study suggests that a CCTA plus S-CMR strategy is effective for the evaluation of patients with suspicion of CCS at low-intermediate risk, and it may help to refine the selection of patients with intermediate coronary plaques at CCTA needing coronary revascularization.

Intravenous Contrast Material for Cardiac Computed Tomography: Results From the Open-label Multicenter, Multivendor Italian Registry of Contrast Material Use in Cardiac Computed Tomography.

PURPOSE: The Italian Registry of Contrast Material use in Cardiac Computed Tomography (iRCM-CCT) is a multicenter, multivendor, observational study on the use of contrast media (CM) in patients undergoing cardiac computed tomography (CCT). The aim of iRCM-CCT is to assess image quality and safety profile of intravenous CM compounds. MATERIALS AND METHODS: iRCM-CCT enrolled 1842 consecutive patients undergoing CCT (≥50 per site) at 20 cluster sites with the indication of suspected coronary artery disease. Demographic characteristics, CCT, and CM protocols, clinical indications, safety markers, radiation dose reports, qualitative (ie, poor vascular enhancement) and quantitative (ie, HU attenuation values) image parameters were recorded. A centralized coordinating center collected and assessed all image parameters. RESULTS: The cohort included 891 men and 951 women (age: 63±14 y, body mass index: 26±4 kg/m2) studied with ≥64 detector rows computed tomography scanners and different iodinated intravenous CM protocols and compounds (iodixanol, iopamidol, iohexol, iobitridol, iopromide, and iomeprol). The following vascular attenuation was reported: 504±147 HU in the aorta, 451±146 HU in the right coronary artery, 474±146 HU in the left main, 451±146 HU in the left anterior descending artery, and 441±149 HU in the circumflex artery. In 4% of cases the image quality was not satisfactory due to poor enhancement. The following adverse reactions to CM were recorded: 6 (0.3%) extravasations and 17 (0.9%) reactions (11 mild, 4 moderate, 2 severe). CONCLUSIONS: In a multicenter registry on CM use during CCT the prevalence of CM-related adverse reactions was very low. The appropriate use of CM is a major determinant of image quality.

The Radiologist as a Gatekeeper in Chest Pain.

Chest pain is a symptom that can be found in life-threatening conditions such as acute coronary syndrome (ACS). Those patients requiring invasive coronary angiography treatment or surgery should be identified. Often the clinical setting and laboratory tests are not sufficient to rule out a coronary or aortic syndrome. Cardiac radiological imaging has evolved in recent years both in magnetic resonance (MR) and in computed tomography (CT). CT, in particular, due to its temporal and spatial resolution, the quickness of the examination, and the availability of scanners, is suitable for the evaluation of these patients. In particular, the latest-generation CT scanners allow the exclusion of diagnoses such as coronary artery disease and aortic pathology, thereby reducing the patient's stay in hospital and safely selecting patients by distinguishing those who do not need further treatment from those who will need more- or less-invasive therapies. CT additionally reduces costs by improving long-term patient outcome. The limitations related to patient characteristics and those related to radiation exposure are weakening with the improvement of CT technology.

Renal pseudoaneurysm after blunt trauma in a 10-year-old girl: A case report.

INTRODUCTION: Renal trauma is a relevant cause of morbidity in children older than 1 year. Most patients are currently managed conservatively, even in case of high-grade traumas; nevertheless, harmful complications may occur even in hemodynamically stable patients. We present a case of grade IV blunt renal trauma complicated by post-traumatic pseudoaneurysm. CASE DESCRIPTION: A 10-year-old girl was referred to our institution for grade IV trauma of the right kidney. During observation she had persistent hematuria that caused anemia. A second contrast-enhanced computed tomography scan revealed a posttraumatic pseudoaneurysm that was successfully treated by angiographic embolization. CONCLUSIONS: Although extremely rare after blunt renal trauma, post-traumatic renal pseudoaneurysm may cause severe blood loss and anemia, and angioembolization is therefore indicated. This condition should be suspected and move physicians to investigate further.

Cardiac magnetic resonance in hypertrophic and dilated cardiomyopathies.

Cardiomyopathies are a heterogeneous entity. The progress in the field of genetics has allowed over the years to determine its origin more and more often. The classification of these pathologies has changed over the years; it has been updated with new knowledge. Imaging allows to define the phenotypic characteristics of the different forms of cardiomyopathy. Cardiac magnetic resonance (CMR) allows a morphological evaluation of the associated (and sometimes pathognomonic) cardiac findings of any form of cardiomyopathy. The tissue characterization sequences also make magnetic resonance imaging unique in its ability to detect changes in myocardial tissue. This review aims to define the features that can be highlighted by CMR in hypertrophic and dilated forms and the possible differential diagnoses. In hypertrophic forms, CMR provides: precise evaluation of wall thickness in all segments, ventricular function and size and evaluation of possible presence of areas of fibrosis as well as changes in myocardial tissue (measurement of T1 mapping and extracellular volume values). In dilated forms, cardiac resonance is the gold standard in the assessment of ventricular volumes. CMR highlights also the potential alterations of the myocardial tissue.

Results of comprehensive cardiovascular diagnostic work-up in HIV positive patients.

Cardiovascular disease (CVD) in the HIV population accounts for a large proportion of morbidity and mortality and, with the increased life expectancy, the burden of CVD is expected to rise. Inflammation, immune dysfunction, side effects of HIV medications, high prevalence of other risk factors are the likely pathogenic mechanisms for accelerated atherosclerosis. We aimed to evaluate the diagnostic yield of a cardiovascular multimodality diagnostic work-up in a contemporary cohort of HIV-infected patients. From November 2017 to October 2019, HIV infected patients were screened in a cardiovascular diagnostic work-up program including clinical history, physical examination, arterial blood pressure measurement, 12-lead ECG, and Transthoracic Echocardiogram (TTE). Advanced non-invasive cardiovascular imaging tests, like Coronary Computed Tomography Angiography (CCTA), stress-echocardiography, Cardiac Magnetic Resonance (CMR), were performed in patients with suspicion of chronic coronary syndrome (CCS) or non-ischemic heart disease (NIHD). 117 HIV-infected consecutive patients underwent this cardiovascular diagnostic work-up and were included in our study. Fifty-two patients (45%) had evidence of CVD. Of them, 22 presented Coronary Artery Disease (CAD), whereas 47 cases showed NIHD. In 17 cases both conditions were present. Among patients with CAD, 8 showed critical coronary stenosis; among them, 5 were treated with percutaneous coronary intervention, 2 with Aorto-Coronary By-Pass Grafting (CABG), and one with medical therapy. Hypertension and diabetes were significantly associated with the development of CVD (respectively p<0.001 and p< 0.05), while current smoking (p<0.02) and hypertension (p<0.007) were positively associated to CAD. A comprehensive cardiovascular diagnostic work-up including advanced multimodality diagnostic imaging modalities led to early detection of CVD in nearly half of an HIV population with immediate interventions required in 6.8% of them, and aggressive prevention treatment started in the remaining HIV patients.

Integration of CTA in the Diagnostic Workup of New Onset Chest Pain in Clinical Practice.

BACKGROUND: Recently, NICE guidelines recommend the use of computed tomographic angiography (CTA) as the first line of investigation for new onset chest pain. We sought to evaluate the impact of the integration of CTA in the diagnostic workup, as either a first- or second-line of investigation, in the clinical practice for patients presenting with new onset chest pain, with suspicion that it may be due to coronary artery disease (CAD). METHOD AND RESULTS: From 2014 to 2016, 208 outpatients (mean age 63.8 ± 12.7, 37% female) with an unknown CAD diagnosis were evaluated. About half (n=106, 51%) received usual testing care plus CTA as a second-line investigation (group A), while the other half (n=102, 49%) received CTA as a first-line investigation (group B). Care decisions and test interpretations were made by the attending physician. Obstructive CAD (O-CAD) was defined as >50% stenosis in the principal branch. As determined by CTA, the rates of CAD in group A vs. group B were the following (P=0.001): 31.1% vs. 27.4% for normal/minimal CAD; 42.5% vs. 63.7% for no O-CAD; and 26.4% vs. 8.8% with O-CAD. Based on a diagnostic result of no O-CAD, invasive angiography was cancelled in 42.6% (n=45) of group A patients, and additional functional tests were cancelled for the same reason in 63.7% (n=65) of group B patients, without adverse events at median 3-year. The average diagnostic cost for patients in our study was lower in group B (206 vs. 324.42 euro; P<0.0001). CONCLUSIONS: In clinical practice, CTA, as a first- or second-line investigation, most commonly detected no O-CAD in new onset chest pain patients, leading us to safely avoid unnecessary ICA or additional functional tests. The use of CTA as a first-line investigation also appears to be cost saving, but its cost-effectiveness remains to be demonstrated in larger studies.

Corrigendum to "Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective".

[This corrects the article DOI: 10.1155/2018/3762305.].

Cerebral small vessel disease and systemic arteriopathy in intracranial arterial dolichoectasia patients.

OBJECTIVES: To investigate clinical and demographic characteristics of patients with intracranial arterial dolichoectasia (IADE) and describe the possible coexistence of cerebral small vessel disease (SVD) and systemic arteriopathy. MATERIAL AND METHODS: From January 2015 to March 2016, all the patients attending an outpatient service for chronic cerebrovascular diseases were screened for suspected IADE. Identified patients underwent a predefined protocol including: brain MR angiography for the diagnosis of IADE; brain MRI with visual rating of SVD features; whole-body CT angiography to assess signs of systemic arteriopathy; and neuropsychological examination. RESULTS: Among the 251 patients screened, IADE was diagnosed in seven (mean age ± SD 68.8 ± 7.2 years, six males). Hypertension was the most frequent risk factor. All patients had basilar artery dolichoectasia, two also ectasia of a vessel of the anterior circulation. All patients had white matter hyperintensities that were moderate or severe in six, five had at least one lacune, and all had enlarged perivascular spaces. At least one microbleed was detected in six patients. A variable grade of global cortical atrophy was found in six patients. Systemic arterial ectasia was found in all but one patient. Neuropsychological examination showed a multidomain cognitive impairment in five patients. CONCLUSIONS: Our study confirms the high prevalence of cerebral SVD in IADE. The involvement of the brain-supplying arteries is probably part of a systemic arteriopathy in IADE patients, thus suggesting the usefulness of assessing the whole arterial tree in clinical practice. Cognitive deterioration signs are frequent in these patients.

Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective.

Stable chest pain is a common clinical presentation that often requires further investigation using noninvasive or invasive testing, resulting in a resource-consuming problem worldwide. At onset of 2016, the National Institute for Health and Care Excellence (NICE) published an update on its guideline on chest pain. Three key changes to the 2010 version were provided by the new NICE guideline. First, the new guideline recommends that the previously proposed pretest probability risk score should no longer be used. Second, they also recommend that a calcium score of zero should no longer be used to rule out coronary artery disease (CAD) in patients with low pretest probability. Third, the new guideline recommends that all patients with new onset chest pain should be investigated with a coronary computed tomographic angiography (CTA) as a first-line investigation. However, in real world the impact of implementation of CTA for the evaluation of new onset chest pain remains to be evaluated, especially regarding its cost effectiveness. The aim of the present report was to discuss the results of the studies supporting new NICE guideline and its comparison with European and US guidelines.

Therapeutic Efficacy of Autologous Non-Mobilized Enriched Circulating Endothelial Progenitors in Patients With Critical Limb Ischemia　- The SCELTA Trial.

BACKGROUND: The therapeutic efficacy of bone marrow mononuclear cells (BM-MNC) autotransplantation in critical limb ischemia (CLI) has been reported. Variable proportions of circulating monocytes express low levels of CD34 (CD14+CD34lowcells) and behave in vitro as endothelial progenitor cells (EPCs). The aim of the present randomized clinical trial was to compare the safety and therapeutic effects of enriched circulating EPCs (ECEPCs) with BM-MNC administration.Methods and Results:ECEPCs (obtained from non-mobilized peripheral blood by immunomagnetic selection of CD14+and CD34+cells) or BM-MNC were injected into the gastrocnemius of the affected limb in 23 and 17 patients, respectively. After a mean of 25.2±18.6-month follow-up, both groups showed significant and progressive improvement in muscle perfusion (primary endpoint), rest pain, consumption of analgesics, pain-free walking distance, wound healing, quality of life, ankle-brachial index, toe-brachial index, and transcutaneous PO2. In ECEPC-treated patients, there was a positive correlation between injected CD14+CD34lowcell counts and the increase in muscle perfusion. The safety profile was comparable between the ECEPC and BM-MNC treatment arms. In both groups, the number of deaths and major amputations was lower compared with eligible untreated patients and historical reference patients. CONCLUSIONS: This study supports previous trials showing the efficacy of BM-MNC autotransplantation in CLI patients and demonstrates comparable therapeutic efficacy between BM-MNC and EPEPCs.

Management of patients presenting with haemoptysis to a Tertiary Care Italian Emergency Department: the Florence Haemoptysis Score (FLHASc).

We analysed the clinical features and diagnostic workup of patients presenting with haemoptysis to an Italian teaching hospital to derive an easy-to-use clinical score to guide risk stratification and initial management in the emergency department (ED). We retrospectively reviewed clinical records of consecutive patients with haemoptysis over 1 year. A pre-specified set of variables, including demographic data, vital signs, type of expectorate (pure blood vs. blood-streaked sputum), comorbidities, and diagnostic tests and treatments was originally registered. The primary outcome was a composite of any of the following: death from any cause, invasive or non-invasive ventilation, Intensive Care Unit admission, blood transfusions or invasive haemostatic procedures. We investigated associations between the pre-specified clinical variables and the primary outcome using a logistic regression analysis. Finally, we derived a score (the Florence Haemoptysis Score, FLHASc) giving a proportional weight to each variable according to the Odds Ratios (OR). We included 197 patients with a median age of 60 years. The first radiological study was a plain chest X-ray in 128 patients (65%). For 33 (17%) patients, a chest computer tomography (CT scan) was the first radiological study. The most common diagnosis was lung malignancy (19% of cases). The diagnosis remained undetermined in one-third of patients. The primary outcome was met by 11.2% of the study population. Systolic blood pressure <100 mmHg (OR 9.7), a history of malignancy (OR 3), the expectoration of pure blood (OR 2.8), and more than 2 episodes of haemoptysis in the prior 24 h (OR 2.5) are found as independent predictors of the primary outcome. The FLHASc ranges from 0 to 6 with a prognostic accuracy of 78% (IC 95%, 68-88%). The primary outcome incidence is 2.4% (IC 95%, 0.2-8.2%) in patients with a FLHASc equal to zero (n = 85, 43%) versus 13.4% (IC 95% 7.8-21.1%) in patients with a FLHASc > 0 (p < 0.01). Among patients with a FLHASc equal to zero, a negative chest X-ray study identifies patients who may be safely discharged. Patients who presented to the ED with haemoptysis experience a heterogeneous management. We derive a simple clinical prognostic score that may rationalize their diagnostic workup.

Prospectively electrocardiogram-triggered high-pitch spiral acquisition coronary computed tomography angiography for assessment of biodegradable vascular scaffold expansion: comparison with optical coherence tomography.

BVS polymeric struts are transparent to the light so that the vessel wall contour can be easily visualized using optical coherence tomography (OCT). Therefore OCT represents a unique tool for both the evaluation of the resorption process and for the assessment of acute BVS mechanical failure. Similarly, the metal-free struts allow unrestricted coronary computed tomography angiography (CCTA), thus this non invasive method might become the gold standard for a non invasive assessment of BVS. In this case we show the ability of CCTA, performed with a low X-Ray dose, to provide a good evaluation of scaffold expansion. The quantitative measurements were in agreement with those obtained with OCT.

A challenging case of epigastric pain: diagnosis and mini-invasive treatment of a large gastroduodenal artery pseudoaneurysm.

The authors present a case of a gastroduodenal artery pseudoaneurysm in a patient with a medical history of pancreatic surgery. The lesion was found and evaluated by ultrasound, CT-angiography and then treated with trans-catheter embolisation. This mini-invasive approach led to a complete resolution of the lesion.

Diagnosis of carotid arterial injury in major trauma using a modification of Memphis criteria.

BACKGROUND: Incidence of Blunt Cerebrovascular Injuries (BCVI) after head injury has been reported as 0.5-1% of all admissions for blunt trauma, with a high stroke and mortality rate. The purpose of this study is to evaluate if a modification of Memphis criteria could improve the rate of BCVI diagnosis. METHODS: Trauma patients consecutively admitted to Intensive Care Unit (ICU) from Jan 2008 to Oct 2009 were considered for the study. Memphis criteria comprehend: basilar skull fracture with involvement of the carotid canal, cervical spine fracture, neurological exam not explained by brain imaging, Horner's syndrome, LeFort II-III fractures, and neck soft tissue injury. As single criteria modification, we included all patients with petrous bone fracture, even without carotid canal involvement. In all patients at risk of BCVI, 64-slice angio-CT-scans was performed. RESULTS: During the study period, 266 patients were admitted to the ICU for blunt major trauma. Among them, 162 presented traumatic brain injury or cervical spine fracture. In accordance with the proposed modified-Memphis criteria, 53 patients showed risk factors for BCVI compared to 45 using the original Memphis criteria. Among the 53 patients, 6 resulted as having carotid lesions (2.2% of all blunt major traumas; one patient more than when using Memphis criteria). Anticoagulant therapy with low molecular weight heparin was administered in all patients. No stroke or hemorrhagic complications occurred. Clinical examination at 6-months showed no central neurological deficit. CONCLUSION: A modification of a single criteria of Memphis screening protocol might permit the identification of a higher percentage of BCVI. Limited by sample size, this study needs to be validated.