Prognostic utility of 64-slice computed tomography in patients with suspected but no documented coronary artery disease.

AIMS: Although multislice computed tomography (MSCT) detects obstructive coronary artery disease (CAD) with high diagnostic accuracy, there is a paucity of long-term prognostic data. We sought to assess the incremental prognostic value of 64-slice CT in patients with suspected but no documented CAD. METHODS AND RESULTS: Coronary MSCT was performed on 227 individuals (61% men, mean age 54 +/- 12 years, 63% with intermediate pre-test probability) without documented CAD, referred for coronary evaluation. Coronary artery disease by MSCT was categorized as follows: none or mild CAD (<50%, n = 172), > or =50% in one vessel (n = 23), two vessels [or in the proximal left anterior descending (LAD), n = 12], and three vessels (or in two vessels including the proximal LAD or left main, n = 20). Baseline risk factors, length of follow-up, and major adverse cardiac events (MACE), including cardiac death, myocardial infarction (MI), and coronary revascularization were recorded. Over a mean follow-up of 2.3 +/- 0.8 years, there were 18 MACE [including four hard events (one cardiac death and three MIs)]. Also, patients with one or more vessel obstructive CAD had increased hard events compared with those with less than one-vessel disease (log-rank statistic P-value 0.01). One or more vessel obstructive CAD was a significant predictor of MACE on univariable and multivariable Cox proportional survival analysis [hazard ratios 29.1 (6.7-126.6) and 9.82 (3.58-27.01), respectively, both P < 0.0001]. In 172 patients, with no or mild CAD, there was 99% freedom from MACE during follow-up. CONCLUSION: Multislice computed tomography-classified extent of CAD provides incremental prognostic information in patients with suspected but no documented CAD.

Transcatheter Mitral Valve Replacement With the Transseptal EVOQUE System.

OBJECTIVES: The aim of this study was to examine the initial experience with a novel transseptal transcatheter mitral valve replacement (TMVR) system. BACKGROUND: Transseptal TMVR may offer a less invasive option than surgery for mitral regurgitation (MR) with greater efficacy and fewer anatomic limitations than transcatheter repair. METHODS: Patients were treated with the EVOQUE TMVR system from September 2018 to October 2019. Key inclusion criteria were moderate or greater MR, New York Heart Association functional class ≥II, and high or prohibitive surgical risk. The primary outcome was technical success, defined by Mitral Valve Academic Research Consortium criteria. RESULTS: Fourteen patients were treated, all with at least moderate to severe MR. The median age was 84 years, and the median Society of Thoracic Surgeons score was 4.6%. MR was degenerative in 4 (28.6%), functional in 3 (21.4%), and mixed in 7 (50%). Technical success was achieved in 13 patients (92.9%), and 1 patient was converted to surgery. At 30 days there was 1 noncardiovascular mortality (7.1%), 2 strokes (14.3%), no myocardial infarctions, and no rehospitalizations. Two patients (14.3%) underwent paravalvular leak closure. One patient (7.1%) underwent alcohol septal ablation for left ventricular outflow tract obstruction. Including the 2 patients with paravalvular leak closure, MR was mild or less in all implanted patients at 30 days, with no MR in 10 (83.3%). Mean mitral gradient was 5.8 mm Hg (median). New York Heart Association functional class improved to ≤II in 9 patients (81.8%). CONCLUSIONS: This first-in-human experience has demonstrated the feasibility of the transseptal EVOQUE TMVR system. Further clinical studies are required to establish safety and clinical outcomes.

Association of total cholesterol/ high-density lipoprotein cholesterol ratio with proximal coronary atherosclerosis detected by multislice computed tomography.

The authors assessed the association between an elevated total cholesterol to high-density lipoprotein cholesterol (TC/HDL-C) ratio (> or = 4) and proximal coronary artery disease (CAD), as observed on multislice computed tomography. Coronary multislice computed tomographic angiography (96% on 40- or 64-slice) was performed in 295 individuals (39% women; mean age, 54 +/- 13 years) without documented CAD who were referred for coronary evaluation. Significant CAD was defined as > or = 50% stenosis in the left main, proximal left anterior descending, or > or = 2 epicardial vessels. Proximal plaque was defined as presence of any plaque in left main or proximal left anterior descending vessels. Individuals with an elevated TC/HDL-C ratio vs those without had a higher prevalence of proximal plaque (62% vs 48%, P = .04) and significant CAD (19% vs 9%, P = .009). On multivariate logistic regression analysis, only age, sex, and TC/HDL-C ratio > or = 4 were associated with significant CAD and proximal plaque.

Association of coronary atherosclerosis detected by multislice computed tomography and traditional risk-factor assessment.

Framingham risk score is an office-based tool used for long-term coronary heart disease risk stratification. Most acute coronary events occur in association with proximal nonobstructive atherosclerotic plaque. Multislice computed tomography detects both obstructive coronary artery disease (CAD) and proximal atherosclerotic plaque with high accuracy. The association of Framingham risk score with obstructive CAD and proximal atherosclerotic plaque was tested. Coronary multislice computed tomography was performed in 295 patients (61% men, mean age 54 +/- 13 years) without documented CAD referred for evaluation of cardiac symptoms. Framingham risk score was computed and patients were stratified according to 10-year risk (n = 213 [72%] low, n = 74 [25%] intermediate, and n = 8 [3%] high). Obstructive CAD was defined as > or =50% stenosis in > or =1 epicardial coronary artery. Proximal atherosclerotic plaque was defined as calcified or noncalcified plaque in the left main or proximal left anterior descending artery. In the low- and intermediate-Framingham risk score groups, there was a high frequency of proximal atherosclerotic plaque (44% and 75%) and obstructive CAD (16% and 34%), although both findings were more prevalent in the high-Framingham risk score group (63% for atherosclerotic plaque, 88% for obstructive CAD), respectively. Proximal atherosclerotic plaque was noncalcified in approximately 13 of patients. In women (n = 114) and younger (<55 years) patients (n = 148), most (93% and 91%, respectively) had a low Framingham risk score. There were 48 women and 51 younger patients with proximal atherosclerotic plaque, of whom only 40% (in each group) were on statin therapy. In conclusion, of patients with a low and intermediate Framingham risk score, a significant proportion had proximal atherosclerotic plaque or obstructive CAD.

Association of anemia with diastolic dysfunction among patients with coronary artery disease in the Heart and Soul Study.

We performed a cross-sectional study to evaluate the association of anemia with diastolic dysfunction and left ventricular hypertrophy (LVH) in outpatients who had coronary artery disease. Logistic regression was used to examine the association of blood hemoglobin (Hb) concentrations with diastolic dysfunction and LVH in 822 participants in the Heart and Soul Study who had normal sinus rhythm and preserved systolic function (left ventricular ejection fraction >/=50%). Using transthoracic echocardiography, diastolic dysfunction was defined as diastolically dominant pulmonary vein flow, and LVH was defined as left ventricular mass index >90 g/m(2). Anemia (Hb <13 g/dl) was present in 24% of participants (197 of 822). The prevalence of diastolic dysfunction ranged from 8% in participants who did not have anemia (Hb >/=13 g/dl) to 13% in those who had moderate anemia (Hb 11 to 13 g/dl) to 24% in those who had severe anemia (Hb <11 g/dl, p = 0.004 for trend). After multivariable adjustment, moderate anemia (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.1 to 3.6) and severe anemia (OR 6.6, 95% CI 1.9 to 24.9) remained strongly associated with diastolic dysfunction. In contrast, moderate anemia (OR 1.4, 95% CI 1.0 to 2.1) and severe anemia (OR 1.6, 95% CI 0.6 to 4.6) were not significantly associated with LVH. We found anemia to be strongly associated with diastolic dysfunction but not with LVH in this community-based sample of outpatients who had established coronary disease.

N-acetylcysteine for the prevention of contrast-induced nephropathy. A systematic review and meta-analysis.

OBJECTIVE: Contrast-induced nephropathy is a common cause of acute renal failure in hospitalized patients. Although patients are often given N-acetylcysteine to prevent renal injury from contrast agents, there are no clear guidelines supporting its use. We conducted a systematic review to determine whether administering N-acetylcysteine around the time of contrast administration reduces the risk of contrast-induced nephropathy. DESIGN: We searched MEDLINE, EMBASE, the Cochrane Collaboration Database, bibliographies of retrieved articles, and abstracts of conference proceedings, and consulted with experts to identify relevant studies. Randomized controlled trials of N-acetylcysteine in hospitalized patients receiving contrast were included. Studies were excluded if they did not report change in creatinine or incidence of contrast-induced nephropathy at 48 hours. MEASUREMENTS AND MAIN RESULTS: Nine randomized controlled trials satisfied all inclusion criteria and were included in the analysis. The difference in mean change in creatinine between the N-acetylcysteine-treated group and controls was -0.27 mg/dl (95% confidence interval [CI], -0.43 to -0.11). The relative risk of developing contrast-induced nephropathy was 0.43 (95% CI, 0.24 to 0.75) in subjects randomized to N-acetylcysteine. Significant heterogeneity existed among studies, suggesting differences in patient populations or study methodology not identified by sensitivity analyses. The incidence of dialysis was rare (0.2%). CONCLUSIONS: Our findings suggest that N-acetylcysteine helps prevent declining renal function and contrast-induced nephropathy. While N-acetylcysteine is inexpensive and nontoxic, undeviating insistence for dosing at least 12 hours in advance of contrast exposure may delay diagnostic and therapeutic procedures. Future studies are needed to address the longer-term clinical outcomes and cost-effectiveness of this agent.

Association of aortic atherosclerosis and renal dysfunction.

BACKGROUND: Both aortic atherosclerosis (AA) and renal dysfunction are associated with increased morbidity and mortality. We sought to assess the association between AA and renal dysfunction. METHODS: The study consisted of 200 consecutive patients (62% were male, mean age 69 +/- 11 years) who underwent transesophageal echocardiography. Demographic and clinical data were recorded. On transesophageal echocardiography, descending and aortic arch atherosclerosis were recorded (in millimeters) using off-line planimetry. The patients were graded with normal AA (group 1, n = 83), mild AA (< or =4 mm in thickness, group 2, n = 53), or severe AA (>4 mm in thickness or complex, group 3, n = 64). Glomerular filtration rate (GFR) (expressed as milliliters/minute/1.73 meters squared) was calculated as 186 x (serum creatinine(-1.154)) x (age(-0.203)) x 1.212 (if black) x 0.742 (if female). RESULTS: The mean GFR decreased significantly with increasing severity of AA (89 +/- 20 for group 1, 72 +/- 20 for group 2, and 49 +/- 23 for group 3, P < .001). Seventy-three percent of patients with severe atherosclerosis compared with 16% patients with no or mild AA had moderate-severe renal dysfunction (GFR < 60; P < .001). On multiple logistic regression, only the size of the AA and the presence of diabetes mellitus were associated with severe (GFR < 30) renal dysfunction (P < .001, odds ratio 65). On receiver operating curve analysis, the area under the curve for AA predicting severe renal dysfunction was 0.90 (P < .0001). CONCLUSION: There exists a strong association between AA and renal dysfunction.

Eptifibatide-induced thrombocytopenia and thrombosis.

Glycoprotein (GP) IIb/IIIa inhibitors have been shown to reduce morbidity and mortality in patients with acute coronary syndromes undergoing percutaneous coronary interventions (PCI). With their widespread use, there is a growing body of literature describing adverse outcomes, including severe thrombocytopenia. Here we report a case of a 75-year-old man who presented with an ST-elevation myocardial infarction, underwent primary PCI and stenting, and subsequently developed profound thrombocytopenia and thrombosis after eptifibatide administration. This report adds to the literature regarding eptifibatide-induced thrombocytopenia and also raises the possibility of a new syndrome of eptifibatide-induced thrombosis. A case is made to examine available databases for thrombosis after administration of eptifibatide and other GPIIb/IIIa inhibitors.