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BACKGROUND: Calcification within chronic total occlusions (CTO) is strongly associated with worse outcomes. Despite the excellent success and safety of intravascular lithotripsy (IVL) in heavily calcified lesions, evidence in CTO remains scarce. AIM: This study aimed to evaluate the procedural and long-term clinical outcomes of IVL in heavily calcified CTO. METHODS: Patients who underwent IVL between 2019 and 2024 from an ongoing prospective multicenter registry were eligible for inclusion. Patients were therefore classified in CTO and non-CTO groups. The efficacy and safety endpoints of CTO percutaneous coronary interventions were defined according to the CTO-ARC consensus. In-hospital major adverse cardiovascular events (MACE) included cardiac death, nonfatal myocardial infarction and target lesion revascularization (TVR). RESULTS: A total of 404 patients underwent IVL, of which the treated lesion was a CTO in 33 (8.2%). The mean J-CTO score was 2.3 ± 1.1. Device success showed no significant difference between CTO and non-CTO groups (100% vs 98.4%; p = 0.35). Comparable technical success with residual stenosis <30% was observed in both groups (90.1% in CTO vs 89.2% in non-CTO, p = 0.83). The incidence of MACE was similar across groups during hospital stays (CTO 6.0% vs. non-CTO 1.9%, p = 0.12), at 30-day (CTO 9.1% vs. non-CTO 3.0%, p = 0.07), and at 12-month follow-up (CTO 9.1% vs. non-CTO 7.3%, p = 0.70). CONCLUSION: IVL provides high procedural success and consistent clinical outcomes in both CTO and non-CTO cases, reinforcing its role in managing heavily calcified coronary lesions.
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Angine de poitrine , Vaisseaux coronaires , Force de la main , Étude de validation de principe , Système nerveux sympathique , Humains , Mâle , Adulte d'âge moyen , Femelle , Système nerveux sympathique/physiopathologie , Vaisseaux coronaires/physiopathologie , Vaisseaux coronaires/imagerie diagnostique , Angine de poitrine/physiopathologie , Sujet âgé , Vasodilatation/physiologie , Maladie des artères coronaires/physiopathologieRÉSUMÉ
BACKGROUND: It has been suggested that coronary microvascular function decreases with age, irrespective of the presence of epicardial atherosclerosis. AIMS: Our aim is to quantitatively investigate the effects of age on microvascular function in patients with normal coronary arteries. METHODS: In 314 patients with angina with no obstructive coronary artery disease (ANOCA), microcirculatory function was tested using the continuous thermodilution method. In 305 patients, the association between age and both resting and hyperaemic myocardial blood flow (Q), microvascular resistance (Rµ), absolute coronary flow reserve (CFR) and microvascular resistance reserve (MRR) was assessed. In addition, patients were divided into 3 groups to test for differences based on age quartiles (≤52 years [24.9%], 53-64 years [49.2%], ≥65 years [25.9%]). RESULTS: The mean age was 59±9 years with a range from 22 to 79 years. The mean resting Q (Qrest) was not different in the 3 age groups (88±34 mL/min, 82±29 mL/min, and 86±38 mL/min, R2=0.001; p=0.62). A trend towards a decreasing mean hyperaemic Q (Qmax) was observed with increasing age (223±79 mL/min, 209±84 mL/min, 200±80 mL/min, R2=0.010; p=0.083). The mean resting Rµ (Rµ,rest) were 1,204±460 Wood units (WU), 1,260±411 WU, and 1,289±455 WU (p=0.23). The mean hyperaemic Rµ (Rµ,hyp) increased significantly with advancing age (429±149 WU, 464±164 WU, 503±162 WU, R2=0.026; p=0.005). Consequently, MRR decreased with age (3.2±1.2, 3.1±1.0, 2.9±0.9; p=0.038). This trend was present in both the patients with (n=121) and without (n=184) coronary microvascular dysfunction (CMD). CONCLUSIONS: There is an age-dependent physiological increase in minimal microvascular resistance and decrease in microvascular function, which is represented by a decreased MRR and is independent of atherosclerosis. The age-dependent decrease in MRR was present in both patients with and without CMD and was most evident in patients with smooth coronary arteries.
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Circulation coronarienne , Vaisseaux coronaires , Microcirculation , Résistance vasculaire , Humains , Adulte d'âge moyen , Mâle , Femelle , Sujet âgé , Vaisseaux coronaires/physiopathologie , Vaisseaux coronaires/imagerie diagnostique , Adulte , Circulation coronarienne/physiologie , Facteurs âges , Résistance vasculaire/physiologie , Jeune adulte , Maladie des artères coronaires/physiopathologie , Angine de poitrine/physiopathologieRÉSUMÉ
Background: Coronary vasomotor dysfunction (CVDys) comprises coronary vasospasm (CVS) and/or coronary microvascular dysfunction (CMD) and is highly prevalent in patients with angina and non-obstructive coronary artery disease (ANOCA). Invasive coronary function testing (CFT) to diagnose CVDys is becoming more common, enabling pathophysiologic research of CVDys. This study aims to explore the electrophysiological characteristics of ANOCA patients with CVDys. Methods: We collected pre-procedural 12-lead electrocardiograms of ANOCA patients with CVS (n = 35), CMD (n = 24), CVS/CMD (n = 26) and patients without CVDys (CFT-, n = 23) who participated in the NL-CFT registry and underwent CFT. Heart axis and conduction times were compared between patients with CVS, CMD or CVS/CMD and patients without CVDys. Results: Heart axis, heart rate, PQ interval and QRS duration were comparable between the groups. A small prolongation of the QT-interval corrected with Bazett (QTcB) and Fridericia (QTcF) was observed in patients with CVDys compared to patients without CVDys (CVS vs CFT-: QTcB = 422 ± 18 vs 414 ± 18 ms (p = 0.14), QTcF = 410 ± 14 vs 406 ± 12 ms (p = 0.21); CMD vs CFT-: QTcB = 426 ± 17 vs 414 ± 18 ms (p = 0.03), QTcF = 413 ± 11 vs 406 ± 12 ms (p = 0.04); CVS/CMD vs CFT-: QTcB = 424 ± 17 vs 414 ± 18 ms (p = 0.05), QTcF = 414 ± 14 vs 406 ± 12 ms (p = 0.04)). Conclusions: Pre-procedural 12-lead electrocardiograms were comparable between patients with and without CVDys undergoing CFT except for a slightly longer QTc interval in patients with CVDys compared to patients without CVDys, suggesting limited cardiac remodeling in patients with CVDys.
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BACKGROUND: P2Y12 inhibitor monotherapy is a promising novel strategy to reduce bleeding complications compared to dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI). In order to personalise treatment with DAPT based on patients' bleeding risk, we compared outcomes after PCI between P2Y12 inhibitor monotherapy and DAPT according to bleeding risk. METHODS: A search for randomized clinical trials (RCTs) comparing P2Y12 inhibitor monotherapy after a short period of DAPT to standard DAPT after PCI was performed. Outcome differences between treatment groups regarding major bleedings, major adverse cardiac and cerebral events (MACCE) and net adverse clinical events (NACE) were assessed with hazard ratios (HRs) and corresponding credible intervals (CrI) according a Bayesian random effects model in patients with and without high bleeding risk (HBR). RESULTS: Five RCTs including 30,084 patients were selected. P2Y12 inhibitor monotherapy compared to DAPT reduced major bleedings in the total population (HR: 0.65, 95 % CrI: 0.44 to 0.92). The HRs of the HBR and non-HBR subgroups showed a similar reduction of bleedings for monotherapy (HBR: HR 0.66, 95 % CrI: 0.25 to 1.74; non-HBR: HR 0.63, 95 % CrI: 0.36 to 1.09). No notable differences between treatments on MACCE and NACE were observed in either sub-group or in the total population. CONCLUSIONS: Regardless of bleeding risk, P2Y12 inhibitor monotherapy is the favourable choice after PCI regarding major bleedings and does not increase ischemic events compared to DAPT. This suggests that bleeding risk is not decisive when considering P2Y12 inhibitor monotherapy.
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Intervention coronarienne percutanée , Antiagrégants plaquettaires , Humains , Antagonistes des récepteurs purinergiques P2Y/usage thérapeutique , Bithérapie antiplaquettaire/effets indésirables , Hémorragie/induit chimiquement , Intervention coronarienne percutanée/effets indésirables , Résultat thérapeutique , Association de médicamentsRÉSUMÉ
In the current review, we emphasize the importance of diagnostics and therapy in patients with ischaemia with no obstructive coronary arteries (INOCA). The importance of the diagnostic coronary function test (CFT) procedure is described, including future components including angiography-derived physiology and invasive continuous thermodilution. Furthermore, the main components of treatment are discussed. Future directions include the national registration ensuring a high quality of INOCA care, besides a potential source to improve our understanding of pathophysiology in the various phenotypes of coronary vascular dysfunction, the diagnostic CFT procedure, and treatment.
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BACKGROUND: Epipericardial fat necrosis (EFN) is a rare cause of chest pain, which is often unrecognized. CASE SUMMARY: A 58-year-old man previously known with a transient ischaemic attack presented with a sharp, substernal chest pain. Pulmonary embolism was ruled out by computed tomography (CT) angiography. However, CT angiography revealed an inhomogeneous epipericardial mass. On cardiovascular magnetic resonance imaging, the mass had an inhomogeneous signal intensity without infiltration of surrounding tissue. Late gadolinium enhancement imaging showed subtle hyperenhancement. Tissue characterization by means of parametric mapping revealed very low native T1 relaxation times and increased T2 relaxation times. In conclusion, the epipericardial mass showed fibrofatty inflammatory markers, suggestive of EFN. The chest pain resolved spontaneously. Follow-up CT 3 months later showed a marked regression of the mass which confirmed the diagnosis EFN. DISCUSSION: Epipericardial fat necrosis is a benign and self-limiting inflammatory cause of chest pain, which can be diagnosed with multi-modality imaging and must not be overlooked in the differential diagnosis of patients with acute pleuritic chest pain.
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AIMS: We aimed to compare semiquantitative coronary computed tomography angiography (CCTA) risk scores - which score presence, extent, composition, stenosis and/or location of coronary artery disease (CAD) - and their prognostic value between patients with and without diabetes mellitus (DM). Risk scores derived from general chest-pain populations are often challenging to apply in DM patients, because of numerous confounders. METHODS: Out of a combined cohort from the Leiden University Medical Center and the CONFIRM registry with 5-year follow-up data, we performed a secondary analysis in diabetic patients with suspected CAD who were clinically referred for CCTA. A total of 732 DM patients was 1:1 propensity-matched with 732 non-DM patients by age, sex and cardiovascular risk factors. A subset of 7 semiquantitative CCTA risk scores was compared between groups: 1) any stenosis ≥50%, 2) any stenosis ≥70%, 3) stenosis-severity component of the coronary artery disease-reporting and data system (CAD-RADS), 4) segment involvement score (SIS), 5) segment stenosis score (SSS), 6) CT-adapted Leaman score (CT-LeSc), and 7) Leiden CCTA risk score. Cox-regression analysis was performed to assess the association between the scores and the primary endpoint of all-cause death and non-fatal myocardial infarction. Also, area under the receiver-operating characteristics curves were compared to evaluate discriminatory ability. RESULTS: A total of 1,464 DM and non-DM patients (mean age 58 ± 12 years, 40% women) underwent CCTA and 155 (11%) events were documented after median follow-up of 5.1 years. In DM patients, the 7 semiquantitative CCTA risk scores were significantly more prevalent or higher as compared to non-DM patients (p ≤ 0.022). All scores were independently associated with the primary endpoint in both patients with and without DM (p ≤ 0.020), with non-significant interaction between the scores and diabetes (interaction p ≥ 0.109). Discriminatory ability of the Leiden CCTA risk score in DM patients was significantly better than any stenosis ≥50% and ≥70% (p = 0.003 and p = 0.007, respectively), but comparable to the CAD-RADS, SIS, SSS and CT-LeSc that also focus on the extent of CAD (p ≥ 0.265). CONCLUSION: Coronary atherosclerosis scoring with semiquantitative CCTA risk scores incorporating the total extent of CAD discriminate major adverse cardiac events well, and might be useful for risk stratification of patients with DM beyond the binary evaluation of obstructive stenosis alone.
Sujet(s)
Angiographie par tomodensitométrie , Coronarographie , Maladie des artères coronaires/imagerie diagnostique , Sténose coronarienne/imagerie diagnostique , Diabète , Tomodensitométrie multidétecteurs , Sujet âgé , Études cas-témoins , Maladie des artères coronaires/épidémiologie , Sténose coronarienne/épidémiologie , Diabète/diagnostic , Diabète/épidémiologie , Évolution de la maladie , Femelle , Humains , Mâle , Adulte d'âge moyen , Valeur prédictive des tests , Pronostic , Score de propension , Enregistrements , Appréciation des risques , Facteurs de risque , Indice de gravité de la maladieRÉSUMÉ
OBJECTIVES: This study was designed to assess the prognostic value of a new comprehensive coronary computed tomography angiography (CTA) score compared with the stenosis severity component of the Coronary Artery Disease-Reporting and Data System (CAD-RADS). BACKGROUND: Current risk assessment with coronary CTA is mainly focused on maximal stenosis severity. Integration of plaque extent, location, and composition in a comprehensive model may improve risk stratification. METHODS: A total of 2,134 patients with suspected but without known CAD were included. The predictive value of the comprehensive CTA score (ranging from 0 to 42 and divided into 3 groups: 0 to 5, 6 to 20, and >20) was compared with the CAD-RADS combined into 3 groups (0% to 30%, 30% to 70% and ≥70% stenosis). Its predictive performance was internally and externally validated (using the 5-year follow-up dataset of the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry], n = 1,971). RESULTS: The mean age of patients was 55 ± 13 years, mean follow-up 3.6 ± 2.8 years, and 130 events (myocardial infarction or death) occurred. The new, comprehensive CTA score showed strong and independent predictive value using the Cox proportional hazard analysis. A model including clinical variables plus comprehensive CTA score showed better discrimination of events compared with a model consisting of clinical variables plus CAD-RADS (0.768 vs. 0.742, p = 0.001). Also, the comprehensive CTA score correctly reclassified a significant proportion of patients compared with the CAD-RADS (net reclassification improvement 12.4%, p < 0.001). Good predictive accuracy was reproduced in the external validation cohort. CONCLUSIONS: The new comprehensive CTA score provides better discrimination and reclassification of events compared with the CAD-RADS score based on stenosis severity only. The score retained similar prognostic accuracy when externally validated. Anatomic risk scores can be improved with the addition of extent, location, and compositional measures of atherosclerotic plaque. (Comprehensive CTA risk score calculator is available at: http://18.224.14.19/calcApp/).
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Angiographie par tomodensitométrie , Coronarographie/méthodes , Maladie des artères coronaires/imagerie diagnostique , Sténose coronarienne/imagerie diagnostique , Vaisseaux coronaires/imagerie diagnostique , Tomodensitométrie multidétecteurs , Adulte , Sujet âgé , Maladie des artères coronaires/complications , Maladie des artères coronaires/mortalité , Sténose coronarienne/complications , Sténose coronarienne/mortalité , Femelle , Humains , Mâle , Adulte d'âge moyen , Infarctus du myocarde/étiologie , Infarctus du myocarde/mortalité , Plaque d'athérosclérose , Valeur prédictive des tests , Survie sans progression , Reproductibilité des résultats , Appréciation des risques , Facteurs de risque , Indice de gravité de la maladieRÉSUMÉ
The best revascularization strategy (complete vs incomplete revascularization) in patients with ST-elevation myocardial infarction (STEMI) is still debated. The interaction between gender and revascularization strategy in patients with STEMI on all-cause mortality is uncertain. The aim of the present study was to evaluate gender-specific difference in all-cause mortality between incomplete and complete revascularization in patients with STEMI and multi-vessel coronary artery disease. The study population consisted of 375 men and 115 women with a first STEMI and multi-vessel coronary artery disease without cardiogenic shock at admission or left main stenosis. The 30-day and 5-year all-cause mortality was examined in patients categorized according to gender and revascularization strategy (incomplete and complete revascularization). Within the first 30 days, men and women with incomplete revascularization were associated with higher mortality rates compared with men with complete revascularization. However, the gender-strategy interaction variable was not independently associated with 30-day mortality after STEMI when corrected for baseline characteristics and angiographic features. Within the survivors of the first 30 days, men with incomplete revascularization (compared with men with complete revascularization) were independently associated with all-cause mortality during 5 years of follow-up (hazard ratios 3.07, 95% confidence interval 1.24;7.61, p = 0.016). In contrast, women with incomplete revascularization were not independently associated with 5-year all-cause mortality (hazard ratios 0.60, 95% confidence interval 0.14;2.51, p = 0.48). In conclusion, no gender-strategy differences occurred in all-cause mortality within 30 days after STEMI. However, in the survivors of the first 30 days, incomplete revascularization in men was independently associated with all-cause mortality during 5-year follow-up, but this was not the case in women.
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Cause de décès , Maladie des artères coronaires/mortalité , Maladie des artères coronaires/chirurgie , Revascularisation myocardique , Intervention coronarienne percutanée/méthodes , Infarctus du myocarde avec sus-décalage du segment ST/mortalité , Infarctus du myocarde avec sus-décalage du segment ST/chirurgie , Sujet âgé , Coronarographie , Maladie des artères coronaires/complications , Électrocardiographie , Femelle , Humains , Mâle , Adulte d'âge moyen , Facteurs de risque , Infarctus du myocarde avec sus-décalage du segment ST/complications , Facteurs sexuels , Résultat thérapeutiqueRÉSUMÉ
Aims: The aim of this study was to determine the long-term prognostic value of infarct size and myocardial ischaemia on single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Methods and results: In total, 1092 STEMI patients who underwent primary PCI and SPECT MPI within 1-6 months were included (median follow-up time of 6.9 years). In the entire cohort, SPECT infarct size was independently associated with the composite of cardiac death or reinfarction [hazard ratio (HR) per 10% increase in summed rest score 1.33; 95% confidence interval (95% CI) 1.12-1.58; P = 0.001], whereas myocardial ischaemia was not (HR per 5% increase in summed difference score 1.18; 95% CI 0.94-1.48; P = 0.16). Addition of SPECT infarct size to a model including the clinical variables provided significant incremental prognostic value for the prediction of cardiac death or reinfarction (global χ2 13.8 vs. 24.2; P = 0.002), whereas addition of SPECT ischaemia did not add significantly (global χ2 24.2 vs. 25.6; P = 0.24). In the subgroup of patients with left ventricular ejection fraction (LVEF) ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction (HR 1.59; 95% CI 1.15-2.22; P = 0.006), whereas in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction (HR 1.28; 95% CI 1.00-1.63; P = 0.050). Conclusion: In patients with first STEMI and primary PCI, SPECT infarct size was independently associated with cardiac death and/or reinfarction, whereas myocardial ischaemia was not. In patients with LVEF ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction, whereas myocardial ischaemia was not. Conversely, in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction.
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Angioplastie coronaire par ballonnet/méthodes , Imagerie de perfusion myocardique/méthodes , Infarctus du myocarde avec sus-décalage du segment ST/imagerie diagnostique , Infarctus du myocarde avec sus-décalage du segment ST/thérapie , Débit systolique/physiologie , Tomographie par émission monophotonique/méthodes , Facteurs âges , Sujet âgé , Analyse de variance , Études de cohortes , Femelle , Humains , Mâle , Adulte d'âge moyen , Pronostic , Modèles des risques proportionnels , Récidive , Études rétrospectives , Appréciation des risques , Infarctus du myocarde avec sus-décalage du segment ST/physiopathologie , Indice de gravité de la maladie , Facteurs sexuels , Taux de survie , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND AND PURPOSE: Patients who received chest irradiation for treatment of a malignancy are at increased risk for the development of coronary artery atherosclerosis. Little is known about the anatomical coronary artery plaque characteristics of irradiation induced coronary artery disease (CAD). This study aimed to evaluate potential differences in the presence, extent, severity, composition and location of CAD in patients treated with mediastinal irradiation compared with non-irradiated controls matched on age, gender and cardiovascular risk factors. MATERIAL AND METHODS: Seventy-nine asymptomatic Hodgkin and non-Hodgkin lymphoma survivors, all treated with mediastinal irradiation with or without chemotherapy, who underwent coronary computed tomography angiography (CTA) to exclude or detect CAD were included. Patients were 1:3 matched with non-irradiated controls (n=237) for age, gender, diabetes, hypertension, hypercholesterolemia, family history of CAD and currently smoking. Mean age at cancer diagnosis was 26±9years and age at the time of coronary CTA was 45±11years. RESULTS: More patients had an abnormal CTA (defined as any coronary artery atherosclerosis): 59% vs. 36% (P<0.001) and significantly more patients had two vessel CAD: 10% vs. 6% and three vessel/left main CAD: 24% vs. 9% compared with controls (overall P<0.001). The maximum stenosis severity among patients was less often <30% (53% vs. 68%) and more often >70% (7% vs. 0%) (overall P=0.001). Patients had more coronary artery plaques in proximal coronary artery segments: left main (17% vs. 6%, P=0.004), proximal left anterior descending artery (30% vs. 16%, P=0.004), proximal right coronary artery (25% vs 10%, P<0.001) and proximal left circumflex artery (14% vs 6%, P=0.022), whereas the number of plaques in non-proximal segments did not differ between groups. CONCLUSIONS: Hodgkin and non-Hodgkin lymphoma survivors treated with mediastinal irradiation with or without chemotherapy showed a higher presence, greater severity, larger extent and more proximally located CAD compared with age, gender and risk factor matched non-irradiated controls. These findings represent features of higher risk CAD and may explain the worse cardiovascular outcome after chest irradiation.
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Coronarographie/méthodes , Maladie des artères coronaires/étiologie , Lymphomes/radiothérapie , Médiastin/effets des radiations , Tomodensitométrie/méthodes , Adulte , Maladie des artères coronaires/imagerie diagnostique , Femelle , Humains , Mâle , Adulte d'âge moyenRÉSUMÉ
AIMS: The aim of this study was to assess the impact of adding stress computed tomography (CT) myocardial perfusion (CTP) to coronary CT angiography (CTA) on downstream referral for invasive coronary angiography (ICA), revascularization, and outcome in patients presenting with new-onset chest pain. METHODS AND RESULTS: Three hundred and eighty-four patients were referred for cardiac CT. Patients with lesions ≥50% stenosis underwent subsequently stress CTP. Perfusion scans were considered abnormal if a defect was observed in ≥ 1 segment. Downstream performance of ICA, revascularization, and the occurrence of major cardiovascular events (death, non-fatal myocardial infarction, and unstable angina requiring urgent revascularization) were assessed within 12 months. In total, 119 patients showed ≥50% stenosis on coronary CTA; stress CTP was normal in 61 patients, abnormal in 38 patients and was not performed in 20 patients. After normal stress CTP, 19 (31%) patients underwent ICA and 9 (15%) underwent revascularization. After abnormal stress CTP, 36 (95%) patients underwent ICA and 29 (76%) revascularizations were performed. Multivariable analyses showed a five-fold reduction in likelihood of proceeding to ICA when a normal stress CTP was added to a coronary CTA showing obstructive CAD. Major cardiovascular event rates at 12 months for patients with obstructive CAD and normal stress CTP (N = 61) were low: 1 myocardial infarction, 1 urgent revascularization, and 1 non-cardiac death. CONCLUSION: The performance of stress CTP in patients with obstructive CAD at coronary CTA in the same setting is feasible and reduces the referral rate for ICA and revascularization. Secondly, the occurrence of major cardiovascular events at 12 months follow-up in patients with normal stress CTP is low.
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Angiographie par tomodensitométrie/méthodes , Coronarographie/méthodes , Sténose coronarienne/imagerie diagnostique , Sténose coronarienne/thérapie , Interprétation d'images assistée par ordinateur , Revascularisation myocardique/mortalité , Sujet âgé , Analyse de variance , Études de cohortes , Sténose coronarienne/mortalité , Sténose coronarienne/physiopathologie , Épreuve d'effort/méthodes , Femelle , Études de suivi , Humains , Mâle , Adulte d'âge moyen , Analyse multifactorielle , Imagerie de perfusion myocardique/méthodes , Revascularisation myocardique/méthodes , Orientation vers un spécialiste , Études rétrospectives , Appréciation des risques , Indice de gravité de la maladie , Analyse de survie , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
OBJECTIVES: The aim of the present study was to evaluate, in low-to-intermediate pre-test probability patients who were referred for coronary computed tomography angiography (CTA) and did not show obstructive coronary artery disease (CAD), whether an intramural course of a coronary artery is associated with worse outcome compared with patients without an intramural course of the coronary arteries. BACKGROUND: The prognostic value of an intramural course of the coronary arteries on coronary CTA in patients without obstructive CAD is not well-known. METHODS: The study population consisted of 947 patients with a low-to-intermediate pre-test probability who were referred for coronary CTA and who did not have obstructive CAD. During follow-up, the occurrence of unstable angina pectoris that required hospitalization, nonfatal myocardial infarction, and all-cause mortality was evaluated. RESULTS: On coronary CTA, 210 patients (22%) had an intramural course of a coronary artery. The median depth of the intramural course was 1.9 mm (interquartile range: 1.4 to 2.6 mm). In 84 patients (40%), the depth of the intramural course was considered deep (>2 mm surrounded by myocardium). During a median follow-up of 4.9 years (interquartile range: 3.2 to 6.9 years), a total of 43 events occurred: hospitalization due to unstable angina pectoris in 13 patients (1.4%); 7 patients (0.7%) had a nonfatal myocardial infarction; and 23 patients died (2.4%). The 6-year cumulative event rate of unstable angina pectoris requiring hospitalization (0.0% vs. 1.1%), nonfatal myocardial infarction (0.5% vs. 0.4%), all-cause mortality (1.9% vs. 2.2%) as well as the combined endpoint of all 3 events (2.4% vs. 3.7%) was similar in patients with and without an intramural course of a coronary artery. CONCLUSIONS: In patients without obstructive CAD on coronary CTA, the presence of an intramural course of a coronary artery was not associated with worse outcome.
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Angiographie par tomodensitométrie , Coronarographie/méthodes , Anomalies congénitales des vaisseaux coronaires/imagerie diagnostique , Vaisseaux coronaires/imagerie diagnostique , Tomodensitométrie multidétecteurs , Adulte , Sujet âgé , Angine de poitrine/étiologie , Cause de décès , Anomalies congénitales des vaisseaux coronaires/complications , Anomalies congénitales des vaisseaux coronaires/mortalité , Bases de données factuelles , Femelle , Finlande , Hospitalisation , Humains , Estimation de Kaplan-Meier , Mâle , Adulte d'âge moyen , Infarctus du myocarde/étiologie , Pays-Bas , Valeur prédictive des tests , Pronostic , Modèles des risques proportionnels , Études rétrospectives , Facteurs de risque , Facteurs tempsRÉSUMÉ
OBJECTIVE: The best strategy in patients with acute ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (CAD) regarding completeness of revascularisation of the non-culprit lesion(s) is still unclear. To establish which strategy should be followed, survival rates over a longer period should be evaluated. The aim of this study was to investigate whether complete revascularisation, compared with incomplete revascularisation, is associated with reduced short-term and long-term all-cause mortality in patients with first STEMI and multivessel CAD. METHODS: This retrospective study consisted of 518 patients with first STEMI with multivessel CAD. Complete revascularisation (45%) was defined as the treatment of any significant coronary artery stenosis (≥70% luminal narrowing) during primary or staged percutaneous coronary intervention prior to discharge. The primary end point was all-cause mortality. RESULTS: Incomplete revascularisation was not independently associated with 30-day all-cause mortality in patients with acute first STEMI and multivessel CAD (OR 1.98; 95% CI 0.62to6.37; p=0.25). During a median long-term follow-up of 6.7 years, patients with STEMI with multivessel CAD and incomplete revascularisation showed higher mortality rates compared with patients who received complete revascularisation (24% vs 12%, p<0.001), and these differences remained after excluding the first 30 days. However, in multivariate analysis, incomplete revascularisation was not independently associated with increased all-cause mortality during long-term follow-up in the group of patients with STEMI who survived the first 30 days post-STEMI (HR 1.53 95% CI 0.89-2.61, p=0.12). CONCLUSION: In patients with acute first STEMI and multivessel CAD, incomplete revascularisation compared with complete revascularisation was not independently associated with increased short-term and long-term all-cause mortality.
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Cardiac sympathetic nervous system dysfunction is closely associated with risk of serious cardiac events in patients with heart failure (HF), including HF progression, pump-failure death, and sudden cardiac death by lethal ventricular arrhythmia. For cardiac sympathetic nervous system imaging, 123I-meta-iodobenzylguanidine (123I-MIBG) was approved by the Japanese Ministry of Health, Labour and Welfare in 1992 and has therefore been widely used since in clinical settings. 123I-MIBG was also later approved by the Food and Drug Administration (FDA) in the United States of America (USA) and it was expected to achieve broad acceptance. In Europe, 123I-MIBG is currently used only for clinical research. This review article is based on a joint symposium of the Japanese Society of Nuclear Cardiology (JSNC) and the American Society of Nuclear Cardiology (ASNC), which was held in the annual meeting of JSNC in July 2016. JSNC members and a member of ASNC discussed the standardization of 123I-MIBG parameters, and clinical aspects of 123I-MIBG with a view to further promoting 123I-MIBG imaging in Asia, the USA, Europe, and the rest of the world.
Sujet(s)
3-Iodobenzyl-guanidine , Techniques d'imagerie cardiaque/méthodes , Techniques de diagnostic neurologique , Cardiopathies/imagerie diagnostique , Coeur/imagerie diagnostique , Coeur/innervation , Système nerveux sympathique/imagerie diagnostique , Europe , Médecine factuelle , Humains , Japon , RadiopharmaceutiquesRÉSUMÉ
BACKGROUND: Epicardial adipose tissue located close to the atrial wall can change the electric conduction of the left atrium, potentially leading to atrial fibrillation (AF). The aim of this study was to assess whether an increased atrial adipose tissue mass posterior to the left atrium is related to AF independent of demographical and cardiovascular risk factors. METHODS AND RESULTS: Two hundred patients with AF and 200 patients without AF who underwent computed tomographic angiography were included. The posterior left atrial adipose tissue mass was quantified on computed tomographic angiography images as tissue with Hounsfield Units between -195 and -45. The adipose tissue mass was significantly larger in patients with AF compared with patients with sinus rhythm: 10.6±5.5 versus 4.7±3.5 g, P<0.001. In a multiple variable model (including age, body mass index, sex, coronary artery calcium score, diabetes mellitus, hypertension, hypercholesterolemia, family history of coronary artery disease, and known coronary artery disease), each gram increase of posterior left atrial adipose tissue was associated with 1.32 odds ratio of having AF (95% confidence interval, 1.22-1.43; P<0.001). Furthermore, the addition of the adipose tissue mass to the multiple variable analysis significantly increased the discriminatory ability to predict AF: increase in the area under the receiver operating characteristic, 0.88 (95% confidence interval, 0.84-0.91) versus 0.81 (0.76-0.85), P<0.001. CONCLUSIONS: Posterior left atrial adipose tissue mass is significantly larger in patients with AF versus without AF. An increase in adipose tissue was independently associated with AF and provided incremental value over well-known predictors of AF. These findings add to the hypothesis that the posterior left atrial adipose tissue mass contributes to structural and electric remodeling leading to AF.
Sujet(s)
Tissu adipeux/anatomopathologie , Fibrillation auriculaire/anatomopathologie , Atrium du coeur/anatomopathologie , Tissu adipeux/imagerie diagnostique , Fibrillation auriculaire/imagerie diagnostique , Angiographie par tomodensitométrie , Produits de contraste , Coronarographie , Femelle , Atrium du coeur/imagerie diagnostique , Humains , Mâle , Adulte d'âge moyen , Péricarde/imagerie diagnostique , Péricarde/anatomopathologie , Facteurs de risqueRÉSUMÉ
Two-dimensional echocardiographic left ventricular (LV) global longitudinal strain (GLS) after ST-segment elevation myocardial infarction (STEMI) is moderately correlated with infarct size and reflects the residual LV systolic function. This correlation may be influenced by the presence of myocardial ischemia. The present study investigated how myocardial ischemia modulates the correlation between LV GLS and infarct size determined with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with first STEMI treated with primary coronary intervention. A total of 1,128 patients (age 60 ± 11 years) who underwent SPECT MPI for the evaluation of infarct size and residual ischemia were evaluated. LV GLS was measured on transthoracic echocardiography. The time interval between echocardiography and SPECT MPI was 1 ± 1 month. A moderate correlation between echocardiographic LV GLS and infarct size on SPECT MPI was observed (r = 0.58, p <0.001). This correlation was weakened by the presence or extent of ischemia; in the group of patients without ischemia, the correlation between LV GLS and infarct size on SPECT MPI was r = 0.66 (p <0.001), whereas in patients with mild or moderate-to-severe ischemia, the correlations were r = 0.56 and 0.38, respectively (both p <0.001). Moderate-to-severe myocardial ischemia was independently associated with more impaired LV GLS after adjusting for infarct size, age, diabetes mellitus, and hypertension (ß 0.60, 95% confidence interval 013 to 1.06). In conclusion, the presence of myocardial ischemia after STEMI impacts on the correlation between echocardiographic LV GLS and infarct size measured on SPECT MPI. Residual ischemia is independently associated with more impaired LV GLS.
Sujet(s)
Infarctus du myocarde/imagerie diagnostique , Infarctus du myocarde/physiopathologie , Ischémie myocardique/imagerie diagnostique , Ischémie myocardique/physiopathologie , Dysfonction ventriculaire gauche/imagerie diagnostique , Dysfonction ventriculaire gauche/physiopathologie , Échocardiographie/méthodes , Femelle , Humains , Interprétation d'images assistée par ordinateur , Mâle , Adulte d'âge moyen , Imagerie de perfusion myocardique , Composés organiques du phosphore , Composés organiques du technétium , Radiopharmaceutiques , Études rétrospectives , Tomographie par émission monophotoniqueRÉSUMÉ
AIMS: The interpretation of adenosine stress myocardial computed tomography perfusion (CTP) is often hampered by image artefacts caused by cardiac motion, beam hardening, and cone beam. The aim of the present analysis was to assess the influence of the heart-rate response during adenosine infusion, patient characteristics, and medication use on the interpretability of stress myocardial CTP examinations. METHODS AND RESULTS: Interpretability of stress myocardial CTP examinations was evaluated in 120 patients who underwent sequentially coronary CTA and adenosine stress myocardial CTP (320-row CT scanner, temporal resolution 175 ms) and scored as follows: excellent = absence of any artefact (n = 27, 22%); good = presence of artefacts that do not interfere with the study interpretability (n = 56, 47%); fair = artefacts that do interfere with interpretability (n = 35, 29%); poor = uninterpretable study due to artefacts (n = 2, 2%). 'Fair' and 'poor' were merged into 'reduced' for comparisons. Increasing heart rate during stress myocardial CTP acquisition was related to worse interpretability (excellent: 61.7 ± 13.4 bpm vs. good: 69.8 ± 13.5 bpm vs. reduced: 78.1 ± 17.0 bpm, P < 0.001). Thirteen (11%) of all examinations were considered non-diagnostic. In patients with a heart rate exceeding 85 bpm, 76% of the studies were 'reduced' interpretable. In multivariate analysis, no use of beta blocker (baseline or additional use prior to coronary CTA) (OR: 0.2, P = 0.012), increasing heart rate during coronary CTA (OR: 1.09, P = 0.032), younger age (OR: 0.92, P = 0.021), and the use of calcium antagonist (OR: 6.48, P = 0.017) were independently associated with a heart rate ≥85 bpm during stress myocardial CTP. CONCLUSION: Higher heart rate during the acquisition of stress myocardial CTP was related to worse interpretability. Furthermore, increasing heart rate during and no beta blocker use prior to the previously performed coronary CTA, younger age, and the use of calcium antagonist were independently associated with a heart rate ≥85 bpm during stress myocardial CTP acquisition.