Effect of Body Mass Index on Effectiveness of CT versus Invasive Coronary Angiography in Stable Chest Pain: The DISCHARGE Trial.

Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%-60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article.

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial.

Importance: The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown. Objective: To determine the association of age with outcomes of CT and ICA in patients with stable chest pain. Design, Setting, and Participants: The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023. Interventions: Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy. Main Outcomes and Measures: MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years. Results: Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients. Conclusions and Relevance: Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02400229.

Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial.

OBJECTIVES: To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status. MATERIALS AND METHODS: This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications). RESULTS: Of 3445 randomised patients with smoking data (mean age 59.1 years + / - 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy. CONCLUSION: For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers. CLINICAL RELEVANCE STATEMENT: This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status. TRIAL REGISTRATION: ClinicalTrials.gov NCT02400229. KEY POINTS: • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.

Computed Tomography Versus Invasive Coronary Angiography in Patients With Diabetes and Suspected Coronary Artery Disease.

OBJECTIVE: To compare cardiac computed tomography (CT) with invasive coronary angiography (ICA) as the initial strategy in patients with diabetes and stable chest pain. RESEARCH DESIGN AND METHODS: This prespecified analysis of the multicenter DISCHARGE trial in 16 European countries was performed in patients with stable chest pain and intermediate pretest probability of coronary artery disease. The primary end point was a major adverse cardiac event (MACE) (cardiovascular death, nonfatal myocardial infarction, or stroke), and the secondary end point was expanded MACE (including transient ischemic attacks and major procedure-related complications). RESULTS: Follow-up at a median of 3.5 years was available in 3,541 patients of whom 557 (CT group n = 263 vs. ICA group n = 294) had diabetes and 2,984 (CT group n = 1,536 vs. ICA group n = 1,448) did not. No statistically significant diabetes interaction was found for MACE (P = 0.45), expanded MACE (P = 0.35), or major procedure-related complications (P = 0.49). In both patients with and without diabetes, the rate of MACE did not differ between CT and ICA groups. In patients with diabetes, the expanded MACE end point occurred less frequently in the CT group than in the ICA group (3.8% [10 of 263] vs. 8.2% [24 of 294], hazard ratio [HR] 0.45 [95% CI 0.22-0.95]), as did the major procedure-related complication rate (0.4% [1 of 263] vs. 2.7% [8 of 294], HR 0.30 [95% CI 0.13 - 0.63]). CONCLUSIONS: In patients with diabetes referred for ICA for the investigation of stable chest pain, a CT-first strategy compared with an ICA-first strategy showed no difference in MACE and may potentially be associated with a lower rate of expanded MACE and major procedure-related complications.

Necessity for introducing the procedure of percutaneous aortic valve implantation in the province of Vojvodina.

INTRODUCTION: Percutaneous aortic valve implantation is an alternative that offers hope to patients who are too old or sick to undergo the conventional surgical aortic valve replacement. The aim of this study was to determine the number of high-risk patients with severe aortic stenosis, hospitalized at the Institute for Cardiovascular Diseases, who are the candidates for percutaneous aortic valve implantation. MATERIAL AND METHODS: The paper prospectively analyzed all patients diagnosed to have severe aortic stenosis who had been hospitalized at the Institute for Cardiovascular Diseases from April 1st, 2011 to October 31st, 2012. Each of these patients was analyzed in relation to the inclusive criteria for percutaneous aortic valve implantation. We analyzed the distribution of these risk factors in relation to age and gender, and the presence of aortic valve replacement surgery by age groups. RESULTS: In the period from April 1st, 2011 to October 31st, 2012, 374 patients diagnosed to have severe aortic stenosis were hospitalized at the Institute for Cardiovascular Diseases. The group of patients older than 80 years had a higher percentage of those patients with low ejection fraction of the heart, chronic pulmonary hypertension and mitral regurgitation. On the other hand, when the total number of surgical aortic valve replacement was taken into consideration with respect to age, there was a significant decrease in their number in the group of patients older than 75 years (41.6%), especially in the age group over 80 years (90.2%). CONCLUSION: The data obtained in this study indicate a high percentage of conservatively treated patients with severe aortic stenosis and high operative risk in patients over 75 years. These data confirm the necessity for the implementation of percutaneous aortic valve replacement in the Province of Vojvodina.

Patency of internal thoracic artery and vein grafts according to revascularized coronary artery properties.

Long-term results of surgical myocardial revascularization are determined by the quality of grafts and the progression of atherosclerosis in coronary arteries. The aim of the study was to evaluate the patency rate of internal thoracic artery and great saphenous vein grafts in relation to the hemodynamic properties of revascularized coronary artery. The patency of internal thoracic artery and great saphenous vein grafts was analyzed in relation to the degree of coronary stenosis estimated by angiography and the diameter of distal portion of coronary artery assessed intra-operatively. The long-term patency of great saphenous grafts depends on the distal coronary artery diameter but not on the degree of coronary artery stenosis. The patency of internal thoracic artery graft depends on the degree of coronary artery stenosis but not on the distal coronary artery diameter. The internal thoracic artery is the superior graft in coronary surgery, but the low patency rate in case of moderate coronary artery stenosis emphasizes the importance of selective approach.

[Hospital infections at the Department of Cardiovascular Surgery].

INTRODUCTION: Despite modern surgical techniques, preoperative preventive use of antibiotics and optimal treatment of operative site, patients who underwent surgical procedures are still at a risk of developing hospital infections. The aim of this paper was to estimate the frequency of hospital infections at the Department of Cardiovascular Surgery and their presence according to the anatomic localization as well as to identify the most frequent causes of hospital infections. MATERIAL AND METHODS: During one-year period, all surgically treated patients were prospectively followed at the Department of Cardiovascular Surgery of the Institute of Cardiovascular Diseases, Vojvodina. There were 1302 patients who underwent 1396 surgical procedures during the period observed The descriptive epidemiological method was applied in the study. The following odds ratio and rates were calculated: the incidence rate of patients with hospital infections, the incidence rate of hospital infections and the incidence rate in relation to hospital stay of each patient (incidence density). RESULTS: During that period, 36 hospital infections were recorded in 33 patients. The average incidence rate of patients with hospital infection was 2.53% and hospital infection rate was 2.58% (from 0% to 5.13%). The male-female ratio was 3.1:1. The most frequent hospital infections were surgical site infections (incidence rate 0.86%), then gastroenteritis (incidence rate 0.77%) and bloodstream infections (incidence rate 0.46%). The most common causes of hospital infections were: Staphylococcus aureus (14.8%), Acinetobacter spp (22.2%) and coagulase negative staphylococcus (11.1%). CONCLUSION: The fact is that the incidence rate of hospital infections is relatively low, and such a trend can continue only if the continuous epidemiological control and preventive measures are implemented in the future.