Factors influencing the safety of outpatient coronary CT angiography: a clinical registry study.

OBJECTIVES: Since the safety of coronary CT angiography (CTA) is of great importance, especially with regard to widening indications and increasing morbidity, the aim of this study was to assess influencing factors. METHODS: Patients undergoing coronary CTA in a third-generation dual-source CT in a radiological centre were included in a clinical registry. Up to 20 mg metoprolol was administered intravenously to attain a heart rate ≤65/min. Glyceryl trinitrate (GTN) was administered in doses of 0.8 mg and 0.4 mg. Blood pressure was measured before the administration and after the CTA. RESULTS: Out of 5500 consecutive patients (3194 men, 62.3 (54.9-70.0) years), adverse events occurred in 68 patients (1.2%) with mild anaphylactoid reactions (0.4%), vasovagal symptoms (0.3%) and extravasation (0.3%) being most frequent. Anti-allergic drugs were given in 17 patients, atropine in 3 patients and volume in 1 patient. Drug administration resulted in a significant mean arterial pressure decline (96.0 (88.3-106.0) vs 108.7 (99.7-117.3) mmHg; p<0.001). Patients who suffered systolic blood pressure drops >20 mmHg or >40 mmHg were older (66.5 (58.6-73.3) vs 60.5 (53.6-68.3) years; 70.2 (63.3-76.5) vs 62.1 (54.7-69.6) years), more often male (65.1% vs 54.4%; 68.9% vs 57.3%) and had higher Agatston score equivalents (83.0 (2.0-432.0) vs 15.0 (0.0-172.0); 163.0 (16.3-830.8) vs 25.0 (0.0-220.0); all p<0.001). GTN dose reduction lowered the fraction of patients suffering from blood pressure drops >20 mmHg or >40 mmHg from 34.5% to 27.4% and from 6.1% to 3.5% (both p<0.001), respectively. The proportion of coronary segments with impaired image quality did not differ significantly. CONCLUSIONS: Coronary CTA with intravenous beta-blocker administration is a safe procedure in an outpatient setting as adverse events are rare and mostly mild. Reduced GTN doses can further improve safety by lowering the rate of significant blood pressure drops, which occurred especially in elderly men with increased plaque burden. TRIAL REGISTRATION NUMBER: NCT03815123.

Short-Time Changes in Coronary Artery Plaques Assessed by Follow-Up Coronary CT Angiography-Characteristics and Impact on Patient Management.

Background: Coronary artery disease (CAD) shows a chronic but heterogeneous clinical course. Coronary CT angiography (CTA) allows for the visualization of the entire coronary tree and the detection of early stages of CAD. The aim of this study was to assess short-time changes in non-calcified and mixed plaques and their clinical impact using coronary CTA in a real-world setting. Methods: Between 11/2014 and 07/2019, 6,701 patients had a coronary CTA with a third-generation dual-source CT, of whom 77 patients (57 males, 63.8 ± 10.8 years) with a chronic CAD received clinically indicated follow-up CTA. Non-calcified and mixed plaques were analyzed in 1,211 coronary segments. Patients were divided into groups: stable, progressive, or regressive plaques. Results: Within the follow-up period of 22.3 ± 10.4 months, 44 patients (58%) showed stable plaques, 27 (36%) showed progression, 5 (7%) showed regression. One patient was excluded due to an undetermined CAD course showing both, progressive and regressive plaques. Age did not differ significantly between groups. Patients with plaque regression were predominantly female (80 vs. 20%), whereas patients showing progression were mainly male (85 vs. 15%; p < 0.01 for both). Regression was only observed in patients with mild CAD or one-vessel disease. The follow-up CTA led to changes in patient management in the majority of subjects (n = 50; 66%). Conclusions: Changes in coronary artery plaques can be observed within a short period resulting in an adjustment of the clinical management in the majority of CAD patients. Follow-up coronary CTA renders the non-invasive assessment of plaque development possible and allows for an individualized diagnostics and therapy optimization.

Evaluation of Serum and Plasma Interleukin-6 Levels in Obstructive Sleep Apnea Syndrome: A Meta-Analysis and Meta-Regression.

Obstructive sleep apnea syndrome (OSAS) is considered a low-grade chronic inflammatory disease. Interleukin-6 (IL-6) is one of the most significant inflammatory markers and an excellent proxy for the inflammatory/immune system. The present meta-analysis and meta-regression aimed at comparing plasma and serum levels of IL-6 between individuals (children and adults) with OSAS and healthy controls. Four databases, PubMed/Medline, Scopus, Cochrane Library, and Web of Science, were comprehensively searched to retrieve articles published up to December, 2019, with no further restrictions. RevMan 5.3 software was used to calculate the crude mean difference (MD) and 95% confidence interval (CI). The results of funnel plots and meta-regression were analyzed by the CMA 2.0 software. Sixty-three studies (57 with adults; six with children) were included in the present meta-analysis. For adults, 37 studies reported significantly higher serum IL-6 levels and 20 reported significantly higher plasma IL-6 levels for those with OSAS than for healthy controls [pooled MD of 2.89 pg/ml (P < 0.00001) and pooled MD of 2.89 pg/ml (P < 0.00001), respectively]. The pooled analysis of serum and plasma IL-6 levels in children with OSAS compared with controls revealed that only the MD of plasma IL-6 levels was significant (MD = 0.84 pg/ml, P = 0.004). Results of the meta-regression showed that greater age was associated with higher serum IL-6 levels. Egger's test revealed a publication bias across the studies for serum and plasma IL-6 levels (P = 0.00044 and P = 0.01445, respectively). In summary, the meta-analysis and meta-regression confirmed that, compared to healthy controls, individuals with OSAS (children and adults) had higher serum/plasma IL-6 levels.

Prognostic significance of semiautomatic quantification of left ventricular long axis shortening in systemic light-chain amyloidosis.

AIMS: To assess left ventricular long axis shortening (LAS) in patients with AL amyloidosis as a potential predictor for outcome. METHODS AND RESULTS: We performed a de novo echocardiographic analysis of LAS in 120 patients with biopsy-proven AL amyloidosis evaluated at first presentation before specific treatment. Additionally, 47 control subjects were analyzed retrospectivly. LAS was measured using a semiautomatic tissue motion annular displacement software algorithm (TMAD). LAS was significantly better than ejection fraction (EF) (p < 0.0001) and M-mode-derived mitral annular plane systolic excursion (MAPSE) (p < 0.05) discriminating AL patients from control subjects, while being non-inferior compared to tissue Doppler-derived peak systolic mitral annular velocity. One year outcome analysis in patients with AL amyloidosis showed that LAS remained the only significant echocardiographic parameter (HR:0.76; p < 0.005) in a multivariable Cox regression model of echocardiographic values. In a comprehensive clinical model, LAS (HR:0.72, p < 0.0001), cardiac troponin-T (HR:2.86, p < 0.01) and free light chain difference (HR:1.00; p < 0.05) were independently associated with the outcome. Assessment of LAS led to a significant integrated discrimination improvement and offered incremental information compared to EF and biomarkers. The cut-off value for LAS discriminating the endpoint was 5.8%. CONCLUSION: LAS was an independent predictor of survival within the first year and offers incremental information in patients with AL amyloidosis evaluated prior to specific treatment.

Rapid assessment of longitudinal systolic left ventricular function using speckle tracking of the mitral annulus.

BACKGROUND: Evaluation of left ventricular function (LV) is one of the most important tasks of echocardiography. Left ventricular longitudinal function has been recognized to differentiate myocardial disorders better than ejection fraction (EF) alone. But recent parameters are still dependent on image quality and time consuming. METHODS: Transthoracic echocardiography, tissue Doppler imaging, strain imaging and assessment of longitudinal function with a tissue motion annular displacement (TMAD) tracking algorithm were performed in 152 patients with various cardiac pathologies and 47 healthy volunteers in a clinical routine setting. RESULTS: Measures of longitudinal function such as LV peak systolic strain (SR, r² = 0.88, p < 0.001) and peak systolic strain rate (SRR, r² = 0.78, p < 0.001) correlated highly with TMAD. Tissue motion annular displacement was ultrafast and less time-consuming compared to strain imaging (8.2 ± 2.2 s, p < 0.001). Significantly more patients with reduced image quality could be analyzed compared to strain imaging (p < 0.001). The intra- and inter-observer variabilities were very low with 1.3 ± 1% and 1.7 ± 1.2%. Tissue motion annular displacement correlated well with clinical parameters (NYHA, r = -0.71, p < 0.001) as well as NT-proBNP (r = -0.73, p < 0.001) and identified patients with structural heart disease with a significantly higher sensitivity 92.1% and specificity 95.7% than did EF, SR, SRR or NT-proBNP (Cut-off:14.2%, p < 0.01). In a subgroup of patients with systemic light chain amyloidosis and preserved EF (>50%, n = 54), TMAD was significantly reduced, especially in those without any signs of cardiac involvement and was superior to other parameters of longitudinal function (p < 0.05). CONCLUSIONS: Tissue motion annular displacement is a rapid, sensitive and reproducible method for the assessment of LV longitudinal function, which is less dependent on image quality.

Longitudinal left ventricular function for prediction of survival in systemic light-chain amyloidosis: incremental value compared with clinical and biochemical markers.

OBJECTIVES: The aim of the study was to determine whether longitudinal left ventricular (LV) function provides prognostic information in a large cohort of patients with systemic light-chain (AL) amyloidosis. BACKGROUND: AL amyloidosis is associated with a high incidence of cardiovascular events. Reduced myocardial longitudinal function is one of the hallmarks of myocardial involvement in this rare disease. METHODS: Two hundred six consecutive patients with biopsy-proven AL amyloidosis were investigated in this prospective observational study. Echocardiographic imaging parameters, mean tissue Doppler-derived longitudinal strain (LS), and two-dimensional global longitudinal strain (2D-GLS) of the LV, cardiac serological biomarkers, and comprehensive clinical disease characteristics were assessed. The primary endpoint was all-cause mortality or heart transplantation. RESULTS: After a median follow-up of 1207 days, LS and 2D-GLS were significant predictors of survival in AL amyloidosis. The cutoff values discriminating survivors from nonsurvivors were -10.65% for LS and -11.78% for 2D-GLS. In a multivariable echocardiographic Cox model, only diastolic dysfunction and 2D-GLS remained as independent predictors of survival. In comprehensive clinical models, 2D-GLS (p < 0.0001), diastolic dysfunction (p < 0.01), the pathologic free light chains (p < 0.05), cardiac troponin-T (cTnT) (p < 0.01), and the Karnofsky index (p < 0.001) remained as independent predictors. 2D-GLS delineated a superior prognostic value compared with that derived from pathologic free light chains or cTnT in patients evaluated before firstline chemotherapy (n = 113; p < 0.0001), and remained the only independent predictor besides the Karnofsky index in subjects with preserved LV ejection fraction (≥50%; n = 127; p < 0.01). LS and 2D-GLS both offered significant incremental information (p < 0.001) for the assessment of outcome compared with clinical variables (age, Karnofsky index, and New York Heart Association functional class) and serological biomarkers. CONCLUSIONS: In the largest serial investigation reported so far, reduced LV longitudinal function served as an independent predictor of survival in AL amyloidosis and offered incremental information beyond standard clinical and serological parameters.