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AIM: To determine the effectiveness of functional stress testing and computed tomography angiography (CTA) for diagnosis of obstructive coronary artery disease (CAD). METHODS AND RESULTS: Two-thousand nine-hundred twenty symptomatic stable chest pain patients were included in the international Collaborative Meta-Analysis of Cardiac CT consortium to compare CTA with exercise electrocardiography (exercise-ECG) and single-photon emission computed tomography (SPECT) for diagnosis of CAD defined as ≥ 50% diameter stenosis by invasive coronary angiography (ICA) as reference standard. Generalised linear mixed models were used for calculating the diagnostic accuracy of each diagnostic test including non-diagnostic results as dependent variables in a logistic regression model with random intercepts and slopes. Covariates were the reference standard ICA, the type of diagnostic method, and their interactions. CTA showed significantly better diagnostic performance (p < 0.0001) with a sensitivity of 94.6% (95% CI 92.7-96) and a specificity of 76.3% (72.2-80) compared to exercise-ECG with 54.9% (47.9-61.7) and 60.9% (53.4-66.3), SPECT with 72.9% (65-79.6) and 44.9% (36.8-53.4), respectively. The positive predictive value of CTA was ≥ 50% in patients with a clinical pretest probability of 10% or more while this was the case for ECG and SPECT at pretest probabilities of ≥ 40 and 28%. CTA reliably excluded obstructive CAD with a post-test probability of below 15% in patients with a pretest probability of up to 74%. CONCLUSION: In patients with stable chest pain, CTA is more effective than functional testing for the diagnosis as well as for reliable exclusion of obstructive CAD. CTA should become widely adopted in patients with intermediate pretest probability. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Database for Systematic Reviews-CRD42012002780. CRITICAL RELEVANCE STATEMENT: In symptomatic stable chest pain patients, coronary CTA is more effective than functional testing for diagnosis and reliable exclusion of obstructive CAD in intermediate pretest probability of CAD. KEY POINTS: Coronary computed tomography angiography showed significantly better diagnostic performance (p < 0.0001) for diagnosis of coronary artery disease compared to exercise-ECG and SPECT. The positive predictive value of coronary computed tomography angiography was ≥ 50% in patients with a clinical pretest probability of at least 10%, for ECG ≥ 40%, and for SPECT 28%. Coronary computed tomography angiography reliably excluded obstructive coronary artery disease with a post-test probability of below 15% in patients with a pretest probability of up to 74%.
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OBJECTIVE: To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. DESIGN: Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. DATA SOURCES: Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. RESULTS: Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). CONCLUSIONS: In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42012002780.
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Angina Pectoris/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Angina Pectoris/etiologia , Doença da Artéria Coronariana/complicações , Estudos de Viabilidade , Humanos , Valor Preditivo dos Testes , ProbabilidadeRESUMO
OBJECTIVES: To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset. METHODS: The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT). RESULTS: 4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models. CONCLUSIONS: Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations. KEY POINTS: ⢠Duke clinical score is not implemented correctly in NICE guideline 95. ⢠Pretest probability assessment in NICE guideline 95 is impossible for most patients. ⢠Improved clinical decision making requires accurate pretest probability calculation. ⢠These refinements are essential for appropriate use of cardiac CT.
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Técnicas de Imagem Cardíaca , Dor no Peito/diagnóstico por imagem , Tomada de Decisão Clínica , Fidelidade a Diretrizes , Guias de Prática Clínica como Assunto , Tomografia Computadorizada por Raios X , Adulto , Idoso , Dor no Peito/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Probabilidade , Fatores de RiscoRESUMO
BACKGROUND: Coronary computed tomography angiography has become the foremost noninvasive imaging modality of the coronary arteries and is used as an alternative to the reference standard, conventional coronary angiography, for direct visualization and detection of coronary artery stenoses in patients with suspected coronary artery disease. Nevertheless, there is considerable debate regarding the optimal target population to maximize clinical performance and patient benefit. The most obvious indication for noninvasive coronary computed tomography angiography in patients with suspected coronary artery disease would be to reliably exclude significant stenosis and, thus, avoid unnecessary invasive conventional coronary angiography. To do this, a test should have, at clinically appropriate pretest likelihoods, minimal false-negative outcomes resulting in a high negative predictive value. However, little is known about the influence of patient characteristics on the clinical predictive values of coronary computed tomography angiography. Previous regular systematic reviews and meta-analyses had to rely on limited summary patient cohort data offered by primary studies. Performing an individual patient data meta-analysis will enable a much more detailed and powerful analysis and thus increase representativeness and generalizability of the results. The individual patient data meta-analysis is registered with the PROSPERO database (CoMe-CCT, CRD42012002780). METHODS/DESIGN: The analysis will include individual patient data from published and unpublished prospective diagnostic accuracy studies comparing coronary computed tomography angiography with conventional coronary angiography. These studies will be identified performing a systematic search in several electronic databases. Corresponding authors will be contacted and asked to provide obligatory and additional data. Risk factors, previous test results and symptoms of individual patients will be used to estimate the pretest likelihood of coronary artery disease. A bivariate random-effects model will be used to calculate pooled mean negative and positive predictive values as well as sensitivity and specificity. The primary outcome of interest will be positive and negative predictive values of coronary computed tomography angiography for the presence of coronary artery disease as a function of pretest likelihood of coronary artery disease, analyzed by meta-regression. As a secondary endpoint, factors that may influence the diagnostic performance and clinical value of computed tomography, such as heart rate and body mass index of patients, number of detector rows, and administration of beta blockade and nitroglycerin, will be investigated by integrating them as further covariates into the bivariate random-effects model. DISCUSSION: This collaborative individual patient data meta-analysis should provide answers to the pivotal question of which patients benefit most from noninvasive coronary computed tomography angiography and thus help to adequately select the right patients for this test.
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Angiografia Coronária/métodos , Doença das Coronárias/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Fatores Etários , Idoso , Angiografia Coronária/normas , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Fatores Sexuais , Tomografia Computadorizada por Raios X/normasRESUMO
Introducción: el conocimiento de la carga aterosclerótica global individual es de alta importancia. Su asociación con los factores de riesgo cardiovascular no está bien establecida. Objetivo: determinar la asociación entre algunos factores de riesgo cardiovascular y el puntaje de calcio coronario. Métodos: se estudiaron 169 pacientes sintomáticos con sospecha de cardiopatía isquémica, que de forma consecutiva se realizaron el puntaje de calcio, se identificaron los factores de riesgo y para determinar su asociación se utilizó el modelo de regresión logística. Resultados: el estudio incluyó 106 mujeres y 63 hombres, edad media 59,6 ± 10,8 años vs. 59,5 ± 11,0 años, respectivamente. El 51,9 pociento de las mujeres y el 34,9 porciento de los hombres tuvieron un score = 0. La dosis media de radiación efectiva fue de 0,82 mSv. Las variables sexo masculino > 55 años, femenino > 65 años, hábito de fumar, diabetes mellitus, edad, número de factores de riesgo, VLDL, triglicéridos y HDL, mostraron asociación significativa con algunos de los valores de corte del puntaje de calcio establecidos. En el análisis multivariado, la edad, el hábito de fumar, los triglicéridos y la HDL como factor protector, tuvieron coeficientes significativamente diferentes de 0, siendo la edad la que tuvo mayor influencia en el valor del score de calcio > 0 y ³ 100 y la HDL en el valor ³ 400. Conclusiones: solamente algunos factores de riesgo muestran asociación con el puntaje de calcio coronario, fundamentalmente la edad y los niveles de HDL como factor protector(AU)
Introduction: knowledge of an individual's overall atherosclerotic burden is extremely important. Its association with cardiovascular risk factors has not been well established. Objective: determine the association between some cardiovascular risk factors and coronary calcium scoring. Methods: a study was conducted of 169 symptomatic patients with suspected ischemic heart disease. The patients consecutively underwent calcium scoring and risk factor identification. Association between the two values was determined by logistic regression modeling. Results: 106 patients were women and 63 were men; mean age was 59.6 ± 10.8 and 59.5 ± 11.0, respectively. 51.9 percent of the women and 34.9 percent of the men had a score = 0. Mean effective radiation dose was 0.82 mSv. The variables male patient aged > 55, female patient aged > 65, smoking, diabetes mellitus, age, number of risk factors, VLDL, triglycerides and HDL showed a significant association with some of the calcium score cut-off values established. In the multivariate analysis, age, smoking, triglycerides and HDL as a protective factor, exhibited coefficients significantly different from 0, with age exerting the greatest influence upon the calcium score > 0 and ³ 100 value, and HDL upon the ³ 400 value. Conclusions: only some risk factors show an association with coronary calcium score, particularly age and HDL levels as a protective factor(AU)
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Doença da Artéria Coronariana/diagnóstico , Cálcio/análise , Fatores de Risco , Doenças Cardiovasculares/diagnóstico , Tomografia/métodos , Epidemiologia Descritiva , Estudos Transversais/métodos , Estudos Observacionais como AssuntoRESUMO
Introducción: el conocimiento de la carga aterosclerótica global individual es de alta importancia. Su asociación con los factores de riesgo cardiovascular no está bien establecida. Objetivo: determinar la asociación entre algunos factores de riesgo cardiovascular y el puntaje de calcio coronario. Métodos: se estudiaron 169 pacientes sintomáticos con sospecha de cardiopatía isquémica, que de forma consecutiva se realizaron el puntaje de calcio, se identificaron los factores de riesgo y para determinar su asociación se utilizó el modelo de regresión logística. Resultados: el estudio incluyó 106 mujeres y 63 hombres, edad media 59,6 ± 10,8 años vs. 59,5 ± 11,0 años, respectivamente. El 51,9 pociento de las mujeres y el 34,9 porciento de los hombres tuvieron un score = 0. La dosis media de radiación efectiva fue de 0,82 mSv. Las variables sexo masculino > 55 años, femenino > 65 años, hábito de fumar, diabetes mellitus, edad, número de factores de riesgo, VLDL, triglicéridos y HDL, mostraron asociación significativa con algunos de los valores de corte del puntaje de calcio establecidos. En el análisis multivariado, la edad, el hábito de fumar, los triglicéridos y la HDL como factor protector, tuvieron coeficientes significativamente diferentes de 0, siendo la edad la que tuvo mayor influencia en el valor del score de calcio > 0 y ³ 100 y la HDL en el valor ³ 400. Conclusiones: solamente algunos factores de riesgo muestran asociación con el puntaje de calcio coronario, fundamentalmente la edad y los niveles de HDL como factor protector
Introduction: knowledge of an individual's overall atherosclerotic burden is extremely important. Its association with cardiovascular risk factors has not been well established. Objective: determine the association between some cardiovascular risk factors and coronary calcium scoring. Methods: a study was conducted of 169 symptomatic patients with suspected ischemic heart disease. The patients consecutively underwent calcium scoring and risk factor identification. Association between the two values was determined by logistic regression modeling. Results: 106 patients were women and 63 were men; mean age was 59.6 ± 10.8 and 59.5 ± 11.0, respectively. 51.9 percent of the women and 34.9 percent of the men had a score = 0. Mean effective radiation dose was 0.82 mSv. The variables male patient aged > 55, female patient aged > 65, smoking, diabetes mellitus, age, number of risk factors, VLDL, triglycerides and HDL showed a significant association with some of the calcium score cut-off values established. In the multivariate analysis, age, smoking, triglycerides and HDL as a protective factor, exhibited coefficients significantly different from 0, with age exerting the greatest influence upon the calcium score > 0 and ³ 100 value, and HDL upon the ³ 400 value. Conclusions: only some risk factors show an association with coronary calcium score, particularly age and HDL levels as a protective factor
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Cálcio/análise , Doença da Artéria Coronariana/diagnóstico , Doenças Cardiovasculares/diagnóstico , Fatores de Risco , Tomografia/métodos , Epidemiologia Descritiva , Estudos Transversais/métodos , Estudos Observacionais como AssuntoRESUMO
Introducción La grasa epicárdica ha mostrado una estrecha asociación con diversos marcadores de aterosclerosis subclínica. Sin embargo, en pacientes con síndrome metabólico (SM) los estudios son escasos y ninguno ha sido realizado en pacientes hispanos. Por ello decidimos evaluar la posible relación de la grasa epicárdica con marcadores de aterosclerosis subclínica y otros factores de riesgo cardiovascular en pacientes con SM. Métodos Se estudiaron 115 pacientes (76 mujeres y 39 hombres, con una edad media de 56,9±8,6 vs 56,7±9,4 años, respectivamente) con diagnóstico de SM. Se recogieron variables clínicas (edad, sexo, antecedentes de tabaquismo, presión arterial sistólica [PAS] y diastólica [PAD]), antropométricas (índice de masa corporal [IMC] y circunferencia de la cintura) y hemoquímicas (glucemia, colesterol total, colesterol HDL, colesterol LDL, triglicéridos, apolipoproteína B [ApoB], apolipoproteína A-I [ApoA-I] y ratio ApoB/ApoA-I). Realizamos además un examen ecocardiográfico transtorácico y carotídeo a todos los participantes, y cuantificación del calcio arterial coronario en 79 pacientes. Resultados La grasa epicárdica mostró una asociación significativa e independiente con la presencia de un grosor íntima-media (GIM) carotídeo >75 percentil (OR: 1,51; IC: 1,22-1,86; p=0,000). Los valores de grasa epicárdica fueron significativamente mayores en los pacientes con presencia de placa ateromatosa carotídea (6,39±1,8 vs 5,14±2,4mm; p=0,007), incremento en los cuartiles de calcificación arterial coronaria (p=0,042) y con un ratio ApoB/ApoA-I elevado para hombres y mujeres (p=0,027, p=0,037, respectivamente).Conclusiones La grasa epicárdica mostró una asociación significativa e independiente con marcadores de aterosclerosis subclínica, así como el ratio ApoB/ApoA-I en pacientes con SM (AU)
Introduction Epicardial fat has been shown to be strongly associated with several markers of subclinical atherosclerosis. However, few studies have been performed in patients with metabolic syndrome and none has been carried out in Hispanic patients. The purpose of our study was to determine the relationship between epicardial fat and markers of subclinical atherosclerosis and other cardiovascular risk factors in patients with metabolic syndrome. Methods A total of 115 patients (76 women and 39 men, mean age 56.9±8.6 vs 56.7±9.4 years, respectively) with metabolic syndrome were studied. We included clinical (age, sex, smoking history, systolic and diastolic blood pressure), anthropometric (body mass index and waist circumference) and biochemical variables (fasting blood glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, apolipoprotein [Apo] B, Apo A-I and the ApoB/ApoA-I ratio). We also performed a transthoracic echocardiography and ultrasonographic carotid examination in all participants as well as coronary artery calcium score quantification in 79 patients. Results Epicardial fat was significantly and independently associated with the presence of carotid intima-media thickness >75th percentile (OR: 1.51; CI: 1.22-1.86; P=.000). Epicardial fat values were significantly higher in patients with carotid plaque (6.39±1.8 vs 5.14±2.4mm, P=.007), an increase in coronary calcium score quartiles (P=.042) and a high ApoB/ApoA-I ratio in both men and women (P=.027 and P=.037, respectively).Conclusions Epicardial fat was significantly and independently associated with several markers of subclinical atherosclerosis, as well as with the ApoB/ApoA-I ratio in patients with metabolic syndrome (AU)
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Humanos , Pericárdio/ultraestrutura , Tecido Adiposo , Aterosclerose/diagnóstico , Síndrome Metabólica/complicações , Fatores de Risco , Apoproteína(a)/análise , Índice de Massa Corporal , Circunferência Abdominal , Colesterol/análiseRESUMO
INTRODUCCIÓN: El score de calcio coronario y la cuantificación del grosor de íntima media son métodos en desarrollo que se utilizan en el diagnóstico de aterosclerosis. OBJETIVO: Evaluar la relación del puntaje de calcio coronario con los factores de riesgo cardiovasculares clásicos y el grosor de la íntima media carotídea. MÉTODOS: Se tomaron 70 pacientes con sospecha de cardiopatía isquémica. A todos se les cuantificó el calcio coronario por tomografía de 64 cortes y el grosor de íntima media en carótidas por ultrasonido. Usando la variable dependiente (score de calcio coronario) de forma continua, fue realizada una regresión lineal simple para obtener los coeficientes de regresión (ß). El nivel de significación estadística (a) con que se trabajó fue del 95 por ciento (valor p < 0,05 como estadísticamente significativo). RESULTADOS: El puntaje de calcio fue superior en individuos del sexo masculino y se incrementó de manera lineal con el decursar de las décadas de edad, por cada año que se incrementa la edad, aumenta en 11,4 UA el score de calcio. El coeficiente de correlación entre el score de calcio y la edad fue de 0,36 estadísticamente significativo (p= 0,002). El 88,9 por ciento de los pacientes con grosor íntima media mayor de 1 mm tenían algún grado de calcificación coronaria, fue 2 veces mayor que los que presentaron un grosor de íntima media menor que 1 mm. El valor de la correlación (r) con el grosor de la íntima media carotídea fue de 0,24 (p= 0,04). CONCLUSIONES: La edad, el sexo masculino y el aumento del grosor íntima media carotídea se relacionan de manera significativa con la presencia y cuantía de la calcificación coronaria(AU)
INTRODUCTION: The coronary calcium's score and the quantification of media intima thickness are developing methods used in atherosclerosis diagnosis. OBJECTIVE: To assess the coronary calcium score relation to classic cardiovascular risk factors and the carotid media intima thickness. METHODS: Sample included 70 patients with suspicion of ischemic heart disease. In all of them the coronary calcium was quantified by 64 scans tomography and the media intima thickness by medias of ultrasound (US). Using continuously the dependent variable (coronary calcium score) we made a simple linear regression to obtain the regression coefficients (ß). The statistic significance level (a) used was of 95 percent (value p < 0,05 as statistically significant). RESULTS: Calcium score was higher in male sex subjects increasing linearly and annually with age in 11.4 UA. The correlation coefficient between calcium score and age was of 0.36 statistically significant (p = 0,002). The 88,9 percent of patients with a media intima thickness greater than 1mm had some degree of coronary calcification, was twice greater than those with a media intima thickness less than 1mm. Correlation value (r) with carotid media intima thickness was of 0.24 (p = 0.04). CONCLUSIONS: Age, male sex and increase of carotid media intima thickness, is significantly related to presence and quantity of coronary calcification(AU)
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Isquemia Miocárdica/diagnóstico , Cálcio/análise , Artérias Carótidas , Doença da Artéria Coronariana/diagnóstico , Tomografia/métodosRESUMO
OBJECTIVE: To determine the accuracy of coronary angiography through 64-slice computed tomography in detecting in-stent restenosis. METHOD: Fifty-two patients with 76 coronary stents and suspicion of restenosis were examined. Initially, they underwent coronary angiography through 64-slice computed tomography, and subsequently invasive coronary angiography as gold standard. Diagnostic efficiency indexes were calculated. RESULTS: In the stents of 3 mm or more of diameter, tomography sensitivity, specificity, positive and negative predictive value were 95, 98, 95 and 98% respectively, with positive likelihood ratio of 42 (CI95%, 6 to 290) and negative of 0.05 (CI95%, .01 to .35), validity of 97% and Kappa of 0.93 (CI95%, .83 to 1), (p ? 0.00001). In the stents smaller than 3 mm, the indexes of diagnostic efficiency and Kappa considerably decreased, loosing the statistical significance (p >0.05). CONCLUSIONS: Coronary angiography through 64-slice computed tomography is an accurate, non-invasive clinical technique for the detection of in-stent restenosis, especially with stents of 3 mm or more of diameter, and reliable allows identification of patients who need to undergo or not control invasive coronary angiography.
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Reestenose Coronária/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Stents , Angiografia Coronária , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores/métodos , Reprodutibilidade dos TestesRESUMO
Objetivo: Determinar la precisión de la coronariografía por tomografía de 64 cortes para la detección de la reestenosis de los stents. Método: Se examinaron 52 pacientes portadores de 76 stents coronarios con sospecha de reestenosis. Inicialmente se les realizó coronariografía mediante tomógrafo de 64 cortes y posteriormente coronariografía invasiva como patrón de referencia. Se calcularon los índices de eficiencia diagnóstica. Resultados: En los stents valorables de 3 mm o más de diámetro, la sensibilidad, especificidad, valor predictivo positivo y negativo de la tomografía fueron de 95, 98, 95 y 98% respectivamente, con razón de verosimilitud positiva de 42 (IC95%, 6 a 290) y negativa de 0.05 (IC95%, 0.01 a 0.35), validez de 97% y Kappa de 0.93 (IC95%, 0.83 a 1), (p ≤ 0.00001). En los stents valorables menores que 3 mm, disminuyeron apreciablemente los índices de eficiencia diagnóstica y de Kappa, perdiendo la significancia estadística (p > 0.05). Conclusión: La coronariografía por tomografía de 64 cortes es una técnica clínica no invasiva precisa, en la detección de la reestenosis de los stents, sobre todo en los stents de 3 mm o más, y segura, ya que permite identificar a los pacientes que necesitan o no la realización de una coronariografía invasiva de control.
Objective: To determine the accuracy of coronary angiography through 64-slice computed tomography in detecting in-stent restenosis. Method: Fifty-two patients with 76 coronary stents and suspicion of restenosis were examined. Initially, they underwent coronary angiography through 64-slice computed tomography, and subsequently invasive coronary angiography as gold standard. Diagnostic efficiency indexes were calculated. Results: In the stents of 3 mm or more of diameter, tomography sensitivity, specificity, positive and negative predictive value were 95, 98, 95 and 98% respectively, with positive likelihood ratio of 42 (CI95%, 6 to 290) and negative of 0.05 (CI95%, .01 to .35), validity of 97% and Kappa of 0.93 (CI95%, .83 to 1), (p ≤ 0.00001). In the stents smaller than 3 mm, the indexes of diagnostic efficiency and Kappa considerably decreased, loosing the statistical significance (p >0.05). Conclusions: Coronary angiography through 64-slice computed tomography is an accurate, non-invasive clinical technique for the detection of in-stent restenosis, especially with stents of 3 mm or more of diameter, and reliable allows identification of patients who need to undergo or not control invasive coronary angiography.
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Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reestenose Coronária , Tomografia Computadorizada Multidetectores , Stents , Angiografia Coronária , Estudos Transversais , Tomografia Computadorizada Multidetectores/métodos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Coronary artery calcium is almost pathognomonic of atherosclerosis. In 1990, Agatston designed a method to measure the coronary calcium score by computed tomography. Our aim was to establish the association between coronary calcified plaque volumes calculated by 64 slice computed tomography and the presence of significant coronary stenosis diagnosed by invasive coronary angiography. METHOD: 150 consecutive patients, 66.6% male, scheduled for invasive coronary angiography were studied. Coronary calcium score was measured per patient and per artery by computed tomography previous to invasive coronary angiography. 128 calcified plaques were enrolled and volume was determined by Callister method introduced in 1998. According to the volume, the plaques were classified in two groups: small if volume ≤ 10 mm3 and big if > 10 mm3. RESULTS: In 79% of plaques with a volume > 10 mm3, significant coronary stenosis was detected by invasive coronary angiography versus 17% with small volume (p < 0.0001). More than 75% of plaques with volume > 10 mm3 in circumflex artery, anterior descending artery and right coronary artery were associated with significant coronary stenosis (p < 0.0001). Spearman correlation was 0.8. The sensitivity and specificity of significant coronary stenosis were 98.7% and 71.7% respectively for a cut off value of 6,5 mm3, area under the curve of 0,88 ± 0,32 (CI 95%, 0.815 to 0.940). CONCLUSIONS: Association between coronary calcified plaque volume diagnosed by computed tomography and the presence of significant coronary stenosis diagnosed by invasive coronary angiography was observed.
Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Calcificação Vascular/diagnóstico por imagem , Doença da Artéria Coronariana/complicações , Estenose Coronária/complicações , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Calcificação Vascular/complicaçõesRESUMO
Introducción: La presencia de calcio en las coronarias es prácticamente patognomónica de aterosclerosis. En el año 1990, Agatston diseño un método para cuantificar el calcio a través de la tomografía. El objetivo del presente trabajo fue determinar el valor del puntaje de calcio coronario para confirmar o descartar obstrucción coronaria significativa. Métodos: Se incluyeron 276 pacientes (80 por ciento del sexo masculino y edad media de 56±10 años) con sospecha de cardiopatía isquémica, a los que inicialmente se les realizó cuantificación del calcio coronario a través de la tomografía de 64 cortes y luego coronariografía por cateterismo. Se determinó sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, razones de verosimilitudes, índice de kappa y validez diagnóstica para puntos de corte 0, 25, 50, 100 y 400 Unidades Agatston (UA) de puntaje de calcio por pacientes y arterias para diagnosticar estenosis coronaria significativa tomando como patrón de referencia la coronariografía invasiva, así como el área bajo la curva ROC. Se consideró significativo una p<0,05 y un índice de confiabilidad del 95 por ciento. Resultados: La sensibilidad, especificidad y el valor predictivo negativo fueron 96 por ciento, 51 por ciento y 92,4 por ciento respectivamente y kappa de 0,46 (IC 95 por ciento, 0,37-0,56), (p<0,0001) para punto de corte 0 UA, y para punto de corte 50 UA fueron 84 por ciento; 80 por ciento y 84 por ciento respectivamente con kappa de 0,64 (IC 95 por ciento, 0,56-0,74), (p<0,0001). El área bajo la curva ROC en el análisis por pacientes fue 0,887±0,020 (0,848-0,926)...
Introduction: The presence of calcium in coronary arteries is practically pathognomonic of the atherosclerosis. In 1990, Agatston designed a method for to quantify the calcium by tomography. The aim of present paper was to determine the coronary calcium score to confirm or to rule out a significant coronary obstruction. Methods: In present study authors included 276 patients (80 percent of male sex and a mean age of 56 ± 10 years) with suspect of ischemic heart disease, who initially underwent a quantification of coronary calcium by 64 scans tomography and then a catheterization coronariography. The sensitivity, specificity, positive and negative predictive value, credibility reasons, Kappa index and diagnostic validity for scan points 0, 25, 50, 100 and 400 Agatston (AU) of calcium score for patients and arteries to diagnose a significant coronary stenosis taking as reference pattern the invasive coronary one, as well as the area under the ROC curve. A p <0,05 and a reliability rate of 95 percent were considered as significant. Results: The sensitivity, specificity and negative predictive value were of 96 percent, 51 percent and 92,4 percent, respectively and a Kappa index of 0,46 (95 percent CI, 0,37-0,56), (p <0,0001) for a scan point 0 UA and for a scan point 50 UA were of 84, percent, 80 percent and 84 percent, respectively with a Kappa index of 0,64 (95 percent CI, 0,56-0,74),(<0,0001). In analysis by patients the area under the ROC curve, the sensitivity, specificity and negative predictive value were of 91 percent, 66 percent and 96 percent, respectively with a Kappa index of 0,43 (95 percent CI, 0,39-0,48), (p<0,0001) and for the scan point 25 UA 83 percent and 94 percent, respectively with a Kappa index of 0,58 (95 percent CI, 0,52-063), (p<0,0001)...
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Doença das Coronárias/diagnóstico , Tomografia/métodos , Cálcio/análise , Cálcio/efeitos adversos , Vasos Coronários , Epidemiologia Descritiva , Estudos TransversaisRESUMO
Introducción: La presencia de calcio en las coronarias es prácticamente patognomónica de aterosclerosis. En el año 1990, Agatston diseño un método para cuantificar el calcio a través de la tomografía. El objetivo del presente trabajo fue determinar el valor del puntaje de calcio coronario para confirmar o descartar obstrucción coronaria significativa. Métodos: Se incluyeron 276 pacientes (80 por ciento del sexo masculino y edad media de 56±10 años) con sospecha de cardiopatía isquémica, a los que inicialmente se les realizó cuantificación del calcio coronario a través de la tomografía de 64 cortes y luego coronariografía por cateterismo. Se determinó sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo, razones de verosimilitudes, índice de kappa y validez diagnóstica para puntos de corte 0, 25, 50, 100 y 400 Unidades Agatston (UA) de puntaje de calcio por pacientes y arterias para diagnosticar estenosis coronaria significativa tomando como patrón de referencia la coronariografía invasiva, así como el área bajo la curva ROC. Se consideró significativo una p<0,05 y un índice de confiabilidad del 95 por ciento. Resultados: La sensibilidad, especificidad y el valor predictivo negativo fueron 96 por ciento, 51 por ciento y 92,4 por ciento respectivamente y kappa de 0,46 (IC 95 por ciento, 0,37-0,56), (p<0,0001) para punto de corte 0 UA, y para punto de corte 50 UA fueron 84 por ciento; 80 por ciento y 84 por ciento respectivamente con kappa de 0,64 (IC 95 por ciento, 0,56-0,74), (p<0,0001). El área bajo la curva ROC en el análisis por pacientes fue 0,887±0,020 (0,848-0,926)...
Introduction: The presence of calcium in coronary arteries is practically pathognomonic of the atherosclerosis. In 1990, Agatston designed a method for to quantify the calcium by tomography. The aim of present paper was to determine the coronary calcium score to confirm or to rule out a significant coronary obstruction. Methods: In present study authors included 276 patients (80 percent of male sex and a mean age of 56 ± 10 years) with suspect of ischemic heart disease, who initially underwent a quantification of coronary calcium by 64 scans tomography and then a catheterization coronariography. The sensitivity, specificity, positive and negative predictive value, credibility reasons, Kappa index and diagnostic validity for scan points 0, 25, 50, 100 and 400 Agatston (AU) of calcium score for patients and arteries to diagnose a significant coronary stenosis taking as reference pattern the invasive coronary one, as well as the area under the ROC curve. A p <0,05 and a reliability rate of 95 percent were considered as significant. Results: The sensitivity, specificity and negative predictive value were of 96 percent, 51 percent and 92,4 percent, respectively and a Kappa index of 0,46 (95 percent CI, 0,37-0,56), (p <0,0001) for a scan point 0 UA and for a scan point 50 UA were of 84, percent, 80 percent and 84 percent, respectively with a Kappa index of 0,64 (95 percent CI, 0,56-0,74),(<0,0001). In analysis by patients the area under the ROC curve, the sensitivity, specificity and negative predictive value were of 91 percent, 66 percent and 96 percent, respectively with a Kappa index of 0,43 (95 percent CI, 0,39-0,48), (p<0,0001) and for the scan point 25 UA 83 percent and 94 percent, respectively with a Kappa index of 0,58 (95 percent CI, 0,52-063), (p<0,0001)...
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Vasos Coronários , Cálcio/análise , Cálcio/efeitos adversos , Doença das Coronárias/diagnóstico , Tomografia/métodos , Estudos Transversais , Epidemiologia DescritivaRESUMO
Introducción: La presencia de calcio en las arterias coronarias es prácticamente patognomónica de aterosclerosis. En 1990, Agatston diseñó un método para cuantificar el puntaje de calcio coronario a través de la tomografía computarizada. Nuestro objetivo fue determinar la asociación entre el volumen de las placas calcificadas en las arterias coronarias determinado por tomografía de 64 cortes y la presencia de estenosis coronaria significativa diagnosticada por coronariografía invasiva. Método: Se estudiaron consecutivamente 150 pacientes, 66.6% varones, programados para coronariografía invasiva. Previo a este procedimiento, se les cuantificó el puntaje de calcio por arteria y por paciente a través de la tomografía. Se incluyeron 128 placas calcificadas, a las que se les determinó el volumen a través del método de Callister introducido en el año 1998. Las placas se consideraron pequeñas si el volumen era ≤ 10 mm³ y grandes si >10 mm³. Resultados: Se asociaron a estenosis coronaria significativa 79% de las placas con volumen mayor a 10 mm³, contra 17% con volumen pequeño (p < 0.0001). Más de 75% de las placas con volumen mayores de 10 mm³ en las arterias circunfleja, descendente anterior y coronaria derecha, se asociaron a estenosis coronaria significativa en el segmento de la placa (p < 0.0001). Correlación de Spearman 0.8. La sensibilidad y especificidad diagnóstica de estenosis coronaria significativa fueron 98.7% y 71.7 % respectivamente para un valor de corte 6.5 mm³ con un área bajo la curva de 0.88 ± 0.32 (IC 95%, 0.815 a 0.940). Conclusiones: Se observó asociación entre el volumen de las placas calcificadas circunscritas en las arterias coronarias diagnosticada por tomografía computada y la presencia de estenosis coronaria significativa diagnosticada por coronariografía invasiva.
Background: Coronary artery calcium is almost patognomonic of atherosclerosis. In 1990, Agatston designed a method to measure the coronary calcium score by computed tomography. Our aim was to establish the association between coronary calcified plaque volumes calculated by 64 slice computed tomography and the presence of significant coronary stenosis diagnosed by invasive coronary angiography. Method: 150 consecutive patients, 66.6% male, scheduled for invasive coronary angiography were studied. Coronary calcium score was measured per patient and per artery by computed tomography previous to invasive coronary angiography. 128 calcified plaques were enrrolled and volume was determined by Callister method introduced in 1998. According to the volume, the plaques were classified in two groups: small if volume ≤ 10 mm³ and big if > 10 mm³. Results: In 79% of plaques with a volume > 10 mm³, significant coronary stenosis was detected by invasive coronary angiography versus 17% with small volume (p < 0.0001). More than 75% of plaques with volume > 10 mm³ in circumflex artery, anterior descending artery and right coronary artery were associated with significant coronary stenosis (p < 0.0001). Spearman correlation was 0.8. The sensitivity and specificity of significant coronary stenosis were 98.7% and 71.7% respectively for a cut off value of 6,5 mm³, area under the curve of 0,88 ± 0,32 (CI 95%, 0.815 to 0.940). Conclusions: Association between coronary calcified plaque volume diagnosed by computed tomography and the presence of significant coronary stenosis diagnosed by invasive coronary angiography was observed.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Angiografia Coronária , Doença da Artéria Coronariana , Estenose Coronária , Tomografia Computadorizada por Raios X , Calcificação Vascular , Estudos Transversais , Doença da Artéria Coronariana/complicações , Estenose Coronária/complicações , Calcificação Vascular/complicaçõesRESUMO
INTRODUCTION AND OBJECTIVES: Multislice computed tomography coronary angiography (MSCT-CA) has been developed in the last years. One of the advantages is to supply information of the lumen and wall of the vessels. The aim was to assess the diagnostic accuracy of MSCT - CA to detect significant coronary stenoses taking as gold standard the invasive coronary angiography (ICA). PATIENTS AND METHODS: We studied, after informed consent, 64 consecutive patients (50 males). First MSCT - CA was performed and afterwards with a media of 45 days the ICA. Sensitivity (SENS), specificity (ESP), positive predictive value (PPV), negative predictive value (NPV) and predictive precision (PP) were assessed per patients, per arteries and per segments. RESULTS: The SENS, ESP, PPV, PNV and PP were 96.4, 91.2, 87, 96.8, 93.5% respectively per patients and 95.7, 97, 88.2, 98.9, 96.7% respectively per arteries and 91, 99, 89, 99.6, 98.7% respectively per segments. The diagnostic accuracy decreased in patients with heart rate higher than 65 beats per minute, as well as in patients with calcium scoring higher than 400 Agatston Units or body mass index with or higher than 30 kg/m2 CS. CONCLUSIONS: Our results suggest that MSCT - CA has a good accuracy, especially in the ESP and NPV for the diagnosis of significant coronary stenoses in selected patients with calcium scoring of 400 Agatston Units or lower, heart rate with 65 beats per minute or lower with regular rhythm and body mass index lower than 30 kg/m2 CS.
Assuntos
Angiografia/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos TestesRESUMO
INTRODUCTION AND OBJECTIVES: Multislice computed tomography coronary angiography (MSCT-CA) has been developed in the last years. One of the advantages is to supply information of the lumen and wall of the vessels. The aim was to assess the diagnostic accuracy of MSCT - CA to detect significant coronary stenoses taking as gold standard the invasive coronary angiography (ICA). PATIENTS AND METHODS: We studied, after informed consent, 64 consecutive patients (50 males). First MSCT - CA was performed and afterwards with a media of 45 days the ICA. Sensitivity (SENS), specificity (ESP), positive predictive value (PPV), negative predictive value (NPV) and predictive precision (PP) were assessed per patients, per arteries and per segments. RESULTS: The SENS, ESP, PPV, PNV and PP were 96.4, 91.2, 87, 96.8, 93.5% respectively per patients and 95.7, 97, 88.2, 98.9, 96.7% respectively per arteries and 91, 99, 89, 99.6, 98.7% respectively per segments. The diagnostic accuracy decreased in patients with heart rate higher than 65 beats per minute, as well as in patients with calcium scoring higher than 400 Agatston Units or body mass index with or higher than 30 kg/m2 CS. CONCLUSIONS: Our results suggest that MSCT - CA has a good accuracy, especially in the ESP and NPV for the diagnosis of significant coronary stenoses in selected patients with calcium scoring of 400 Agatston Units or lower, heart rate with 65 beats per minute or lower with regular rhythm and body mass index lower than 30 kg/m2 CS.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Angiografia/métodos , Doença da Artéria Coronariana , Tomografia Computadorizada por Raios X , Reprodutibilidade dos TestesRESUMO
La cirugía cardiaca con circulación extracorpórea se acompaña de complicaciones relacionadas con el síndrome de respuesta inflamatoria sistémica. En los últimos años se ha retomado la cirugía con el corazón latiendo. Determinar la evolución posoperatoria inmediata en dos grupos de pacientes en los que se empleó en un grupo la circulación extracorpórea con pinzamiento aórtico y paro anóxico durante el proceder de revascularización y otro grupo en el que la operación se realizó a corazón batiente. La muestra se subdividió en dos grupos de pacientes, los cuales fueron operados consecutivamente. En el Grupo C, se empleó circulación extracorpórea con paro anóxico por pinzamiento aórtico y protección con cardioplejia en el proceder de revascularización con puentes aortocoronarios y el Grupo S, en el que esta se realizó con el corazón latiendo. Se estudiaron 110 pacientes, operados consecutivamente por un mismo grupo de cirujanos y anestesiólogos. El grupo S, necesitó menor empleo de inotrópicos y hemoderivados, menor tiempo de ventilación artificial mecánica, menor estadía en la unidad de cuidados intensivos, sin embargo la revascularización completa fue mayor en el grupo C. La revascularización con el corazón latiendo es factible y ventajosa en pacientes en los que la anatomía coronaria permita realizar una revascularización completa(AU)