Evaluation of stable chest pain following emergency department presentation: Impact of first-line cardiac computed tomography diagnostic strategy in an Australian setting.

OBJECTIVE: International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first-line for outpatient stable chest pain evaluation was implemented in an Australian ED. METHODS: In pre-post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6-month pre-implementation group (February 2021 to July 2021). CTCA was recommended first-line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. RESULTS: Three hundred and fifteen patients were included, 143 pre-implementation and 172 post-implementation. Characteristics were similar except age (pre-implementation: 58.9 ± 12.0 vs post-implementation: 62.8 ± 12.3 years, P = 0.004). Pathway-guided management resulted in higher first-line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non-invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre-implementation: 13.3% vs post-implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post-implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30-day myocardial infarction or death occurred. CONCLUSIONS: The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.

Does Systemic Sclerosis-associated Interstitial Lung Disease Burn Out? Specific Phenotypes of Disease Progression.

RATIONALE: Previous studies have suggested that interstitial lung disease (ILD) progresses most rapidly early in the course of systemic sclerosis-associated (SSc)-ILD, and that SSc-ILD is often more stable or even "burned out" after the first 4 years following diagnosis. OBJECTIVES: Our objectives were to determine whether an apparent plateau in pulmonary function decline is due to survival bias and to identify distinct prognostic phenotypes of ILD progression. METHODS: Consecutive patients with SSc-ILD from a single center were included. Pulmonary function measurements were typically performed every 6 months. Study participants were categorized into long-term survivors (>8 yr survival from diagnosis), and those with medium-term and short-term mortality (4-8 and <4 yr survival, respectively). We excluded those censored with less than 8 years of follow-up. Subject-specific slopes for change in forced vital capacity (FVC) and diffusing capacity of the lung for carbon monoxide (DlCO) were calculated using generalized linear models with mixed effects. The rate of decline in FVC was compared across prognostic groups. RESULTS: The cohort included 171 study participants with SSc-ILD. A plateau in the progression of FVC was apparent in the full cohort analysis but disappeared with stratification into prognostic subgroups to account for survival bias. Those with short-term mortality had a higher annual rate of decline in FVC (-4.10 [95% confidence interval (CI), -7.92 to -0.28] vs. -2.14 [95% CI, -3.31 to -0.97] and -0.94 [-1.46 to -0.42]; P = 0.003) and DlCO (-5.28 [95% CI, -9.58 to -0.99] vs. -3.13 [95% CI, -4.35 to -1.92] and -1.32 [95% CI, -2.01 to -0.63]; P < 0.001) than those with medium-term mortality and long-term survival with adjustment for age, sex, and pack-years. Change in FVC in the previous year did not predict FVC change in the subsequent year. CONCLUSIONS: Adults with SSc-ILD have distinct patterns of physiological progression that remain relatively consistent during long-term follow-up; however, recent change in FVC cannot be used to predict future change in FVC within shorter follow-up intervals. The findings of this study provide important information on the course of disease in SSc-ILD and identify specific phenotypes of progression that may improve clinical decision-making and design of future therapeutic trials.

Oesophageal diameter is associated with severity but not progression of systemic sclerosis-associated interstitial lung disease.

BACKGROUND AND OBJECTIVE: It is unknown whether oesophageal disease is associated with systemic sclerosis-associated interstitial lung disease (SSc-ILD) severity, progression or mortality. METHODS: High-resolution computed tomography (HRCT) scans from 145 SSc-ILD patients were scored for fibrosis score, oesophageal diameter and presence of hiatal hernia. Fibrosis asymmetry was calculated as: (most affected side - least affected side)/(most affected side + least affected side). Mixed effects models were used for repeated measures analyses. RESULTS: Mean fibrosis score was 8.6%, and most patients had mild-to-moderate physiological impairment. Every 1 cm increase in oesophageal diameter was associated with 1.8% higher fibrosis score and 5.5% lower forced vital capacity (FVC; P ≤ 0.001 for unadjusted and adjusted analyses). Patients with hiatal hernia had 3.9% higher fibrosis score, with persistent differences on adjusted analysis (P = 0.001). Oesophageal diameter predicted worsening fibrosis score over the subsequent year (P = 0.02), but not when adjusting for baseline fibrosis score (P = 0.16). Oesophageal diameter was independently associated with mortality (P = 0.001). Oesophageal diameter was not associated with asymmetric disease or radiological features of gross aspiration. CONCLUSION: Oesophageal diameter and hiatal hernia are independently associated with SSc-ILD severity and mortality, but not with ILD progression or asymmetric disease. Oesophageal disease is unlikely to be a significant driver of ILD progression in SSc.

Multimodality Imaging for Planning and Follow-up of Transcatheter Aortic Valve Replacement.

The complementary modalities of Doppler echocardiography and multidetector computed tomography are most frequently used for the planning and follow-up of transcatheter aortic valve replacement (TAVR). TAVR is now a well-established modality in the treatment of high-risk and inoperable patients with symptomatic severe aortic stenosis. Furthermore, recent studies have shown that TAVR is equivalent or superior to surgical aortic valve replacement in patients at intermediate surgical risk. We review the most commonly used imaging modalities and discuss their respective strengths and contributions to optimal patient selection, procedure planning, implementation, and follow-up in TAVR.

Comparison of low-dose coronary artery calcium scoring using low tube current technique and hybrid iterative reconstruction vs. filtered back projection.

INTRODUCTION: We sought to validate whether low dose CACS CT with hybrid IR (HIR) could replace standard dose filtered back projection (FBP). METHOD: We enrolled 100 patients to undergo low dose CACS CT with HIR, in addition to routine full dose FBP. RESULTS: No significant difference between full and low dose CT in Agatston score 138.2±360.6 vs. 137.3±356.4 (p=0.272) or calcium mass score 19±48.3 vs. 18.7±49 (p=0.8), respectively. Bland-Altman analysis showed no systematic bias. Calcium volume difference was statistically significant 57.2±134 vs. 55.1±130.2 (p=0.001). CONCLUSION: Low dose CT for calcium scoring with HIR enables stable CACS Agatston score and calcium mass quantification as compared to full dose FBP.

Computed tomography assessment for transcatheter aortic valve in valve implantation: The vancouver approach to predict anatomical risk for coronary obstruction and other considerations.

Valve-in-valve implantation of a transcatheter heart valve into a failed bioprosthetic heart valve has emerged as a treatment alternative to repeat conventional surgery. This requires careful pre-procedural assessment using non-invasive imaging to identify patients at risk for procedure related adverse events, such as ostial coronary occlusion. Herein we report how to comprehensively assess aortic root anatomy using computed tomography prior to transcatheter valve implantation for failed bioprosthetic aortic valves.

Long-Term Prognostic Utility of Coronary CT Angiography in Stable Patients With Diabetes Mellitus.

OBJECTIVES: The goal of this study was to determine the long-term prognostic value of coronary computed tomography angiography (CTA) among patients with diabetes mellitus (DM) compared with nondiabetic subjects. BACKGROUND: The long-term prognostic value of coronary CTA in patients with DM is not well established. METHODS: Patients enrolled in the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry with 5-year follow-up data were identified. The extent and severity of coronary artery disease (CAD) were analyzed at baseline coronary CTA and in relation to outcomes between diabetic and nondiabetic patients. CAD according to coronary CTA was defined as none (0% stenosis), nonobstructive (1% to 49% stenosis), or obstructive (≥50% stenosis). Time to death (and in a subgroup, time to major adverse cardiovascular event) was estimated by using multivariable Cox proportional hazards models. RESULTS: A total of 1,823 patients were identified as having DM with 5-year clinical follow-up and were propensity-matched to 1,823 patients without DM (mean age 61.8 ± 10.9 years; 54.4% male). Patients with DM did not exhibit a heightened risk of death compared with the propensity-matched nondiabetic subjects in the absence of CAD on coronary CTA (risk-adjusted hazard ratio [HR] of DM: 1.32; 95% confidence interval [CI]: 0.78 to 2.24; p = 0.296). Patients with DM were at increased risk of dying compared with nondiabetic subjects in the setting of nonobstructive CAD (in the propensity-matched cohort: HR, 2.10; 95% CI: 1.43 to 3.09; p < 0.001) with a mortality risk greater than nondiabetic subjects with obstructive disease (p < 0.001). In a risk-adjusted hazard analysis among patients with DM, both per-patient obstructive CAD and nonobstructive CAD conferred an increase in all-cause mortality risk compared with patients without atherosclerosis on coronary CTA (nonobstructive disease-HR: 2.07; 95% CI: 1.33 to 3.24; p = 0.001; obstructive disease-HR: 2.22; 95% CI: 1.47 to 3.36; p < 0.001). CONCLUSIONS: Among patients with DM, nonobstructive and obstructive CAD according to coronary CTA were associated with higher rates of all-cause mortality and major adverse cardiovascular events at 5 years, and this risk was significantly higher than in nondiabetic subjects. Importantly, patients with DM without CAD according to coronary CTA were at a risk comparable to that of nondiabetic subjects.

The effect of a whole heart motion-correction algorithm on CT image quality and measurement reproducibility in Pre-TAVR aortic annulus evaluation.

BACKGROUND: Motion correction (MC) algorithms have been shown to improve image quality, interpretability and diagnostic accuracy in coronary CT angiography. We sought to determine whether MC extended to the whole heart would demonstrate improved image quality and reproducibility of aortic annular measurements in pre-TAVR CT. MATERIALS AND METHODS: Twenty-two consecutive contrast enhanced CT data sets acquired for pre TAVR evaluation using retrospective ECG synchronization during a single heart beat were retrospectively identified. Image data sets were obtained from raw data acquired at 35% and 75% of the R-R interval using both standard (STD) and motion corrected (MC) reconstruction algorithms. Four data sets (2 STD, 2 MC) per patient were analyzed by 2 independent, blinded readers for aortic annular area, short and long axis, perimeter and average diameter. Image quality was graded using a 5 point Likert score (1 and 2 non diagnostic, 5 excellent). Statistical analysis was performed using Wilcoxon matched paired tests, Bland-Altman (B-A) plots and Lin's concordance coefficient comparing 35% STD to 35% MC, and 75% STD to 75% MC. RESULTS: Eighty-eight datasets were analyzed (44 STD, 44 MC). At 35%, there was a significant improvement in image quality for MC (Likert score 3.3 ± 0.9 STD vs. 3.9 ± 0.7 MC, p < 0.007). While B-A analysis demonstrated narrower interobserver agreement for aortic annular area (bias 0.03 vs 0.02 cm(2), range -0.32 to 0.39 cm(2) vs -0.50 to 0.55 cm(2)), and perimeter (bias 0.3 vs 0.3 mm, range -3.1 to 3.8 mm vs -4.6 to 5.3 mm), this was not statistically significant by concordance correlation coefficient. At 75%, there was no significant difference in image quality (Likert score 3.3 ± 0.9 vs. 3.5 ± 0.76, p = 0.454) or annular measurement agreement intervals. CONCLUSION: Motion correction algorithms may yield significant improvements of image quality in systolic CT data sets of the heart. Further validation studies are required to determine the effect on annular measurements and translation into clinical practice.

Long term prognostic utility of coronary CT angiography in patients with no modifiable coronary artery disease risk factors: Results from the 5 year follow-up of the CONFIRM International Multicenter Registry.

BACKGROUND: Coronary computed tomography angiography (coronary CTA) can prognosticate outcomes in patients without modifiable risk factors over medium term follow-up. This ability was driven by major adverse cardiovascular events (MACE). OBJECTIVE: Determine if coronary CTA could discriminate risk of mortality with longer term follow-up. In addition we sought to determine the long-term relationship to MACE. METHODS: From 12 centers, 1884 patients undergoing coronary CTA without prior coronary artery disease (CAD) or any modifiable CAD risk factors were identified. The presence of CAD was classified as none (0% stenosis), mild (1% to 49% stenosis) and obstructive (≥50% stenosis severity). The primary endpoint was all-cause mortality and the secondary endpoint was MACE. MACE was defined as the combination of death, nonfatal myocardial infarction, unstable angina, and late target vessel revascularization (>90 days). RESULTS: Mean age was 55.6 ± 14.5 years. At mean 5.6 ± 1.3 years follow-up, 145(7.7%) deaths occurred. All-cause mortality demonstrated a dose-response relationship to the severity and number of coronary vessels exhibiting CAD. Increased mortality was observed for >1 segment non-obstructive CAD (hazard ratio [HR]:1.73; 95% confidence interval [CI]: 1.07-2.79; p = 0.025), obstructive 1&2 vessel CAD (HR: 1.70; 95% CI: 1.08-2.71; p = 0.023) and 3-vessel or left main CAD (HR: 2.87; 95% CI: 1.57-5.23; p = 0.001). Both obstructive CAD (HR: 6.63; 95% CI: 3.91-11.26; p < 0.001) and non-obstructive CAD (HR: 2.20; 95% CI: 1.31-3.67; p = 0.003) predicted MACE with increased hazard associated with increasing CAD severity; 5.60% in no CAD, 13.24% in non-obstructive and 36.28% in obstructive CAD, p < 0.001 for trend. CONCLUSIONS: In individuals being assessed for CAD with no modifiable risk factors, all-cause mortality in the long term (>5 years) was predicted by the presence of more than 1 segment of non-obstructive plaque, obstructive 1- or 2-vessel CAD and 3 vessel/left main CAD. Any CAD, whether non-obstructive or obstructive, predicted MACE over the same time period.