Impact of Smoking on Coronary Volume-to-Myocardial Mass Ratio: An ADVANCE Registry Substudy.

Purpose To examine the relationship between smoking status and coronary volume-to-myocardial mass ratio (V/M) among individuals with coronary artery disease (CAD) undergoing CT fractional flow reserve (CT-FFR) analysis. Materials and Methods In this secondary analysis, participants from the ADVANCE registry evaluated for suspected CAD from July 15, 2015, to October 20, 2017, who were found to have coronary stenosis of 30% or greater at coronary CT angiography (CCTA) were included if they had known smoking status and underwent CT-FFR and V/M analysis. CCTA images were segmented to calculate coronary volume and myocardial mass. V/M was compared between smoking groups, and predictors of low V/M were determined. Results The sample for analysis included 503 current smokers, 1060 former smokers, and 1311 never-smokers (2874 participants; 1906 male participants). After adjustment for demographic and clinical factors, former smokers had greater coronary volume than never-smokers (former smokers, 3021.7 mm3 ± 934.0 [SD]; never-smokers, 2967.6 mm3 ± 978.0; P = .002), while current smokers had increased myocardial mass compared with never-smokers (current smokers, 127.8 g ± 32.9; never-smokers, 118.0 g ± 32.5; P = .02). However, both current and former smokers had lower V/M than never-smokers (current smokers, 24.1 mm3/g ± 7.9; former smokers, 24.9 mm3/g ± 7.1; never-smokers, 25.8 mm3/g ± 7.4; P < .001 [unadjusted] and P = .002 [unadjusted], respectively). Current smoking status (odds ratio [OR], 0.74 [95% CI: 0.59, 0.93]; P = .009), former smoking status (OR, 0.81 [95% CI: 0.68, 0.97]; P = .02), stenosis of 50% or greater (OR, 0.62 [95% CI: 0.52, 0.74]; P < .001), and diabetes (OR, 0.67 [95% CI: 0.56, 0.82]; P < .001) were independent predictors of low V/M. Conclusion Both current and former smoking status were independently associated with low V/M. Keywords: CT Angiography, Cardiac, Heart, Ischemia/Infarction Clinical trial registration no. NCT02499679 Supplemental material is available for this article. © RSNA, 2024.

Impact of Coronary CT Angiography-derived Fractional Flow Reserve on Downstream Management and Clinical Outcomes in Individuals with and without Diabetes.

Purpose: To compare the clinical use of coronary CT angiography (CCTA)-derived fractional flow reserve (FFR) in individuals with and without diabetes mellitus (DM). Materials and Methods: This secondary analysis included participants (enrolled July 2015 to October 2017) from the prospective, multicenter, international The Assessing Diagnostic Value of Noninvasive CT-FFR in Coronary Care (ADVANCE) registry (ClinicalTrials.gov identifier, NCT02499679) who were evaluated for suspected coronary artery disease (CAD), with one or more coronary stenosis ≥30% on CCTA images, using CT-FFR. CCTA and CT-FFR findings, treatment strategies at 90 days, and clinical outcomes at 1-year follow-up were compared in participants with and without DM. Results: The study included 4290 participants (mean age, 66 years ± 10 [SD]; 66% male participants; 22% participants with DM). Participants with DM had more obstructive CAD (one or more coronary stenosis ≥50%; 78.8% vs 70.6%, P < .001), multivessel CAD (three-vessel obstructive CAD; 18.9% vs 11.2%, P < .001), and proportionally more vessels with CT-FFR ≤ 0.8 (74.3% vs 64.6%, P < .001). Treatment reclassification by CT-FFR occurred in two-thirds of participants which was consistent regardless of the presence of DM. There was a similar graded increase in coronary revascularization with declining CT-FFR in both groups. At 1 year, presence of DM was associated with higher rates of major adverse cardiovascular events (hazard ratio, 2.2; 95% CI: 1.2, 4.1; P = .01). However, no between group differences were observed when stratified by stenosis severity (<50% or ≥50%) or CT-FFR positivity. Conclusion: Both anatomic CCTA findings and CT-FFR demonstrated a more complex pattern of CAD in participants with versus without DM. Rates of treatment reclassification were similar regardless of the presence of DM, and DM was not an adverse prognostic indicator when adjusted for diameter stenosis and CT-FFR.Clinical trial registration no. NCT 02499679Keywords: Fractional Flow Reserve, CT Angiography, Diabetes Mellitus, Coronary Artery Disease Supplemental material is available for this article. See also the commentary by Ghoshhajra in this issue.© RSNA, 2023.

A narrative review on yoga: a potential intervention for augmenting immunomodulation and mental health in COVID-19.

BACKGROUND: The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has a significant mortality rate of 3-5%. The principal causes of multiorgan failure and death are cytokine release syndrome and immune dysfunction. Stress, anxiety, and depression has been aggravated by the pandemic and its resultant restrictions in day-to-day life which may contribute to immune dysregulation. Thus, immunity strengthening and the prevention of cytokine release syndrome are important for preventing and minimizing mortality in COVID-19 patients. However, despite a few specific remedies that now exist for the SARS-CoV-2virus, the principal modes of prevention include vaccination, masking, and holistic healing methods, such as yoga. Currently, extensive research is being conducted to better understand the neuroendocrinoimmunological mechanisms by which yoga alleviates stress and inflammation. This review article explores the anti-inflammatory and immune-modulating potentials of yoga, along with its role in reducing risk for immune dysfunction and impaired mental health. METHODS: We conducted this narrative review from published literature in MEDLINE, EMBASE, COCHRANE databases. Screening was performed for titles and abstracts by two independent review authors; potentially eligible citations were retrieved for full-text review. References of included articles and articles of major non-indexed peer reviewed journals were searched for relevance by two independent review authors. A third review author checked the excluded records. All disagreements were resolved through discussion amongst review authors or through adjudication by a fourth review author. Abstracts, editorials, conference proceedings and clinical trial registrations were excluded. OBSERVATIONS: Yoga is a nonpharmacological, cost-effective, and safe intervention associated with several health benefits. Originating in ancient India, this vast discipline consists of postures (asanas), breathing techniques (pranayama), meditation (dhyana/dharana), and relaxation. Studies have demonstrated yoga's ability to bolster innate immunity and to inhibit cytokine release syndrome. As an intervention, yoga has been shown to improve mental health, as it alleviates anxiety, depression, and stress and enhances mindfulness, self-control, and self-regulation. Yoga has been correlated with numerous cardioprotective effects, which also may play a role in COVID-19 by preventing lung and cardiac injury. CONCLUSION AND RELEVANCE: This review paves the path for further research on yoga as a potential intervention for enhancing innate immunity and mental health and thus its role in prevention and adjunctive treatment in COVID-19.

Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE.

OBJECTIVES: This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) according to sex. BACKGROUND: Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFRCT improves sex-based patient management decisions compared to CCTA alone is unknown. METHODS: Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFRCT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFRCT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates. RESULTS: A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFRCT. Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFRCT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFRCT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFRCT ≤0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFRCT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm3/g vs. 24.76 ± 7.22 mm3/g; p < 0.0001) that is associated with higher FFRCT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFRCT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284). CONCLUSIONS: FFRCT differs between the sexes, as women have a higher FFRCT for the same degree of stenosis. In FFRCT-positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFRCT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679).

Effect of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve on Physicians' Clinical Behavior　- Differences Between Sites With and Without Appropriate Use Criteria as Designated by the Japanese Reimbursement System.

Background: Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) is an established tool for identifying lesion-specific ischemia that is now approved for use by the Japanese insurance system. However, current clinical reimbursement is strictly limited to institutions with designated appropriate use criteria (AUC). This study assessed differences in physicians' behavior (e.g., use and interpretation of FFRCT, final management) according to Japanese AUC and non-AUC site designation. Methods and Results: Of 5,083 patients in the ADVANCE Registry, 1,829 from Japan were enrolled in this study. Physicians' behavior after interrogating CCTA and FFRCT was analyzed separately according to AUC and non-AUC site designation. Compared with AUC sites, patients referred for FFRCT from non-AUC sites had a higher rate of negative FFRCT, less severe anatomic stenosis, and a slightly lower rate of management plan reclassification (51.2% vs. 61.3%), with near-identical utility in both groups. Actual care corresponded equally well to post-FFRCT plans in both groups. The likelihood of revascularization for positive or negative FFRCT was similar between the 2 groups. Importantly, AUC and non-AUC sites were equally unlikely to revascularize patients with negative FFRCT and stenosis >50% or patients with positive FFRCT and stenosis <50%. Conclusions: Compared with AUC sites, non-AUC sites had lower disease burden and reclassification of management plans, but nearly identical clinical integration. Actual care corresponded equally well to post-FFRCT recommendations at both sites.

Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department.

OBJECTIVES: This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFRCT) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program. BACKGROUND: FFRCT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied. METHODS: ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFRCT were studied. FFRCT ≤0.80 was considered positive for hemodynamically significant stenosis. RESULTS: Among 555 patients, 297 underwent coronary CTA and FFRCT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFRCT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFRCT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFRCT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFRCT when revascularization was deferred. Negative FFRCT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFRCT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFRCT groups ($8,582 vs. $8,048; p = 0.550). CONCLUSIONS: In ACP, FFRCT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFRCT, which is associated with higher nonobstructive disease on invasive angiography.

Coronary Computed Tomography Angiography: Enhancing Risk Stratification and Diagnosis of Cardiovascular Disease in Women.

PURPOSE OF REVIEW: There are numerous gender- and sex-based differences that contribute to the increased morbidity and mortality related to atherosclerotic cardiovascular disease (ASCVD) in women. Early detection of risk and targeted management of atherosclerotic disease is fundamental to reduce ASCVD risk and improve outcomes in women. In this review, we examine the utility of cardiac computed tomography (CT) and coronary CT angiography (CTA) in three ASCVD scenarios including coronary artery calcium scoring for risk stratification in asymptomatic women, and coronary CTA for diagnosis and prognosis of stable ischemic heart disease and acute chest pain. The risks of radiation exposure and the potential applications of novel technologies in women are explored. RECENT FINDINGS: CTA provides the capabilities of early recognition and management of nonobstructive coronary artery disease (CAD). Recent advancements in plaque composition and morphology further enhance the prognostic yield from coronary CTA. Innovations in stress perfusion and computational fluid dynamics allow for evaluation of physiological measures of ischemia. In addition, developments in artificial intelligence (AI) may also help unlock a deeper understanding of atherosclerosis and risk in women. Coronary CTA is an accurate and useful modality for early detection and management of ASCVD in women. Novel technologies hold great promise for furthering our understanding of sex-specific pathophysiology and potential improvement in clinical management and outcomes.

Role of stress management for cardiovascular disease prevention.

PURPOSE OF REVIEW: Despite the significant decline in cardiovascular disease (CVD) rates owing to recognition of risk factors, timely and appropriate therapy for acute events, and improved medical therapy, it remains the leading cause of death globally. Novel risk factors and modifications must be considered in the development and progression of CVD. The purpose of this review is to delineate the association between psychological and mental stress and CVD. RECENT FINDINGS: Stress has been implicated as a significant risk factor in both the acceleration of atherosclerosis and a trigger for acute CVD events. In the last decade, a growing body of evidence has been accumulated on the biological, neuroanatomical, and neurophysiological effects of stress and the benefits of cultivating resilience. The pathophysiology of stress is complex and involves the brain, autonomic nervous system, and the endocrine system, with associated metabolic, inflammatory, and hemostatic abnormalities. SUMMARY: Most practice guidelines do not recognize the importance of screening for stress in primary and secondary CVD prevention. There is a paucity of large, scalable, and cost-effective approaches for stress intervention. Two potential strategies are required for reducing stress: strategies that are population-based, and narrower targeted strategies for clinical practice.

Clinical Impact of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve on Japanese Population in the ADVANCE Registry.

BACKGROUND: Coronary computed tomography angiography (cCTA)-derived fractional flow reserve (FFRCT) is a promising diagnostic method for the evaluation of coronary artery disease (CAD). However, clinical data regarding FFRCTin Japan are scarce, so we assessed the clinical impact of using FFRCTin a Japanese population.Methods and Results:The ADVANCE registry is an international prospective FFRCTregistry of patients suspected of CAD. Of 5,083 patients, 1,829 subjects enrolled from Japan were analyzed. Demographics, symptoms, cCTA, FFRCT, treatment strategy, and 90-day major cardiovascular events (MACE) were assessed. Reclassification of treatment strategy between cCTA alone and cCTA+FFRCToccurred in 55.8% of site investigations and in 56.9% in the core laboratory analysis. Patients with positive FFR (FFRCT≤0.80) were less likely to have non-obstructive disease on invasive coronary angiography than patients with negative FFR (FFRCT>0.80) (20.5% vs. 46.1%, P=0.0001). After FFRCT, 67.0% of patients with positive results underwent revascularization, whereas 96.1% of patients with negative FFRCTwere medically treated. MACE occurred in 5 patients with positive FFRCT, but none occurred in patients with negative FFRCTwithin 90 days. CONCLUSIONS: In this Japanese population, FFRCTmodified the treatment strategy in more than half of the patients. FFRCTshowed potential for stratifying patients suspected of CAD properly into invasive or non-invasive management pathways.

Coronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting.

Noninvasive fractional flow reserve derived from coronary CT angiography (FFRCT) is increasingly used in patients with coronary artery disease as a gatekeeper to the catheterization laboratory. While there is emerging evidence of the clinical benefit of FFRCT in patients with moderate coronary disease as determined with coronary CT angiography, there has been less focus on interpretation, reporting, and integration of FFRCT results into routine clinical practice. Because FFRCT analysis provides a plethora of information regarding pressure and flow across the entire coronary tree, standardized criteria on interpretation and reporting of the FFRCT analysis result are of crucial importance both in context of the clinical adoption and in future research. This report represents expert opinion and recommendation on a standardized FFRCT interpretation and reporting approach. Published under a CC BY 4.0 license.

Coronary computed tomographic imaging in women: An expert consensus statement from the Society of Cardiovascular Computed Tomography.

This expert consensus statement from the Society of Cardiovascular Computed Tomography (SCCT) provides an evidence synthesis on the use of computed tomography (CT) imaging for diagnosis and risk stratification of coronary artery disease in women. From large patient and population cohorts of asymptomatic women, detection of any coronary artery calcium that identifies females with a 10-year atherosclerotic cardiovascular disease risk of >7.5% may more effectively triage women who may benefit from pharmacologic therapy. In addition to accurate detection of obstructive coronary artery disease (CAD), CT angiography (CTA) identifies nonobstructive atherosclerotic plaque extent and composition which is otherwise not detected by alternative stress testing modalities. Moreover, CTA has superior risk stratification when compared to stress testing in symptomatic women with stable chest pain (or equivalent) symptoms. For the evaluation of symptomatic women both in the emergency department and the outpatient setting, there is abundant evidence from large observational registries and multi-center randomized trials, that CT imaging is an effective procedure. Although radiation doses are far less for CT when compared to nuclear imaging, radiation dose reduction strategies should be applied in all women undergoing CT imaging. Effective and appropriate use of CT imaging can provide the means for improved detection of at-risk women and thereby focus preventive management resulting in long-term risk reduction and improved clinical outcomes.

Incidence and predictors of lesion-specific ischemia by FFRCT: Learnings from the international ADVANCE registry.

BACKGROUND: To date, the clinical utility of coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT) has been limited to trials and single center experiences. We herein report the incidence of abnormal FFRCT (≤0.80) and the relationship of lesion-specific ischemia to subject demographics, symptoms, and degree of stenosis in the multicenter, prospective ADVANCE registry. METHODS: One thousand patients with suspected angina having documented coronary artery disease on coronary CTA and clinically referred for FFRCT were prospectively enrolled in the registry. Patient demographics, symptom status, coronary CTA and FFRCT findings were recorded. Univariate and multivariate analyses were performed to investigate the predictors related to abnormal FFRCT. RESULTS: FFRCT data were analyzed in 952 patients (95.2%). Overall, 51.1% patients had a positive FFRCT value (≤0.80). Patients with ≥3 risk factors had a significantly higher rate of abnormal FFRCT than those with <3 risk factors (60.2% vs. 43.9%, p = 0.0001). On multivariate analysis, baseline diabetes (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.04-2.21, p = 0.030) and hypertension (OR 1.56, 95%CI 1.14-2.14, p = 0.005) were both predictive of abnormal FFRCT. In addition, >70% stenosis was significantly associated with low FFRCT (OR 31.16, 95%CI 12.25-79.22, p < 0.0001) vs. <30% stenosis. Notably, stenosis 30-49% vs. <30% had an increased likelihood of ischemia (OR 3.74, 95%CI 1.52-9.17, p < 0.0001). CONCLUSIONS: In this real-world registry, CT angiographic stenosis severity in addition to baseline cardiovascular risk factors conferred an increased likelihood of an abnormal FFRCT. Importantly, however, mild CT angiographic stenoses were noted to have an increased hazard for ischemia and the converse holding true for more severe stenoses as well.

Trials of Quality Improvement in Imaging.

Cardiovascular imaging plays a central role in the diagnosis and treatment of cardiovascular disease. Recently, increased emphasis has been placed on quality in cardiovascular imaging, and it is becoming a central priority for various stakeholders, including patients, physicians, and payers. The changing health care landscape and associated challenges imposed on cardiac imagers, including reductions in reimbursement and growing need for pre-authorization, have also helped bring quality metrics to the forefront. Continuous quality improvement initiatives provide the framework for the team of physicians, technical staff members, administrators, and other health care professionals to deliver high-quality care. Efforts to improve quality in cardiac imaging have started to form the foundation for numerous research studies in this arena, and although few in number, randomized control trials have begun to emerge. This review highlights quality improvement studies focusing on appropriate use education, reporting, and radiation dose reduction in cardiovascular imaging.

Rationale, design and goals of the HeartFlow assessing diagnostic value of non-invasive FFRCT in Coronary Care (ADVANCE) registry.

BACKGROUND: Coronary CT angiography (CTA) is a reliable tool for the detection of coronary artery disease (CAD) that conveys significant prognostic information. It does not provide data on the hemodynamic significance of a given lesion, particularly in intermediate-grade stenosis. Fractional flow reserve by CT (FFRCT) can accurately predict the hemodynamic significance of coronary lesions. The primary objective of this registry is to determine whether the integration of FFRCT as an adjunct to coronary CTA will lead to a significant change in the management of CAD in patients with stable angina. METHODS: The ADVANCE Registry is a multi-center, prospective registry designed to evaluate utility, clinical outcomes and resource utilization following FFRCT-guided treatment in clinically stable, symptomatic patients diagnosed with CAD by coronary CTA. Approximately 5000 patients will be enrolled from up to 50 sites in Europe, USA, Canada and Asia. Requirement for enrollment is the presence of atherosclerosis on coronary CTA. For each enrolled patient, a clinical management review committee will use data from coronary CTA and FFRCT to determine the management plan using the following criteria: (a) optimal medical therapy, (b) percutaneous coronary intervention, (c) coronary artery bypass graft surgery, or (d) more information required. The primary endpoint of the registry is the reclassification rate between the management plan based on coronary CTA alone versus CTA plus FFRCT. The secondary endpoints of the registry include the evaluation of the rate of invasive coronary angiography (ICA), revascularization, major adverse coronary events, resource utilization, cumulative radiation dose exposure and the rate of ICA without obstructive CAD at 3-year follow-up. CONCLUSIONS: The ADVANCE registry is designed to assess the real-world impact of FFRCT on the clinical management of stable CAD when used along with coronary CTA.

Coronary CT Angiography in the Emergency Department: Current Status.

OPINION STATEMENT: Acute chest pain (ACP) represents a clinical as well as economic challenge, often resulting in time-consuming, expensive evaluations to avoid missed diagnosis of acute coronary syndromes (ACSs). Coronary CT angiography (CTA) is an attractive noninvasive technique for use in the emergency department (ED) due to its high accuracy and negative predictive value. Recent studies have demonstrated that coronary CTA can aid in safe, rapid, and cost-efficient triage of these patients. Additional applications of plaque characterization, fractional flow analysis, and CT perfusion imaging hold promise in providing incremental data in patients with suspected ACS. In this review, we examine the data for the use of coronary CTA in acute chest pain, novel applications of the technology, and best practice for its use in the ED.

The role of cardiac CT in women.

Due to the discrepancy between higher symptom burden and lower disease prevalence, the diagnosis of coronary artery disease (CAD) in women is challenging. Cardiac CT can be particularly useful in CAD diagnosis and risk stratification in women. In this review, we explore cardiac CT in women with and without symptoms and for adjudication of functional tests. Novel CT technologies such as fractional flow reserve and stress perfusion imaging and their potential for usefulness in women are also examined.