Coronary Artery Calcium Score Predicts Major Adverse Cardiovascular Events in Stable Chest Pain.

Background Coronary artery calcium (CAC) has prognostic value for major adverse cardiovascular events (MACE) in asymptomatic individuals, whereas its role in symptomatic patients is less clear. Purpose To assess the prognostic value of CAC scoring for MACE in participants with stable chest pain initially referred for invasive coronary angiography (ICA). Materials and Methods This prespecified subgroup analysis from the 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 across 26 centers in 16 countries, focused on adult patients with stable chest pain referred for ICA. Participants were randomly assigned to undergo either ICA or coronary CT. CAC scores from noncontrast CT scans were categorized into low, intermediate, and high groups based on scores of 0, 1-399, and 400 or higher, respectively. The end point of the study was the occurrence of MACE (myocardial infarction, stroke, and cardiovascular death) over a median 3.5-year follow-up, analyzed using Cox proportional hazard regression tests. Results The study involved 1749 participants (mean age, 60 years ± 10 [SD]; 992 female). The prevalence of obstructive coronary artery disease (CAD) at CT angiography rose from 4.1% (95% CI: 2.8, 5.8) in the CAC score 0 group to 76.1% (95% CI: 70.3, 81.2) in the CAC score 400 or higher group. Revascularization rates increased from 1.7% to 46.2% across the same groups (P < .001). The CAC score 0 group had a lower MACE risk (0.5%; HR, 0.08 [95% CI: 0.02, 0.30]; P < .001), as did the 1-399 CAC score group (1.9%; HR, 0.27 [95% CI: 0.13, 0.59]; P = .001), compared with the 400 or higher CAC score group (6.8%). No significant difference in MACE between sexes was observed (P = .68). Conclusion In participants with stable chest pain initially referred for ICA, a CAC score of 0 showed very low risk of MACE, and higher CAC scores showed increasing risk of obstructive CAD, revascularization, and MACE at follow-up. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Hanneman and Gulsin in this issue.

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.

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.

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial.

OBJECTIVE: To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease. DESIGN: Prospective, multicentre, randomised pragmatic trial. SETTING: Hospitals at 26 sites in 16 European countries. PARTICIPANTS: 2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%. INTERVENTION: Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group. MAIN OUTCOME MEASURES: The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications. RESULTS: Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%) v 41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%) v 21 (2.1%); hazard ratio 0.14, 0.04 to 0.46). CONCLUSION: This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men. TRIAL REGISTRATION: NCT02400229ClinicalTrials.gov NCT02400229.

CT or Invasive Coronary Angiography in Stable Chest Pain.

BACKGROUND: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. METHODS: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. RESULTS: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). CONCLUSIONS: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.).

Radiologic correlation between the thickness of the roof of the glenoid fossa and that of the bony covering of the superior semicircular canal.

OBJECTIVES: Dehiscence of the superior semicircular canal (SSC) has been associated with alteration of the temporomandibular joint, although data explaining this association are lacking. The present study examined the correlations between the presence of dehiscences and thickness of the bone covering the SSC and the roof of the glenoid fossa (RGF). STUDY DESIGN: Computed tomography was used in a cross-sectional analysis of the presence of dehiscences and thickness of the bone overlying the SCC and RGF in 156 temporal bones of 78 patients. The correlations of the presence of dehiscences in the SSC and ipsilateral RGF and the thickness of bone covering the SSC and RGF were analyzed by using the χ2 or Fisher's exact test. The relationship between the thickness of the bone overlying the SCC and RGF was analyzed by using the Spearman correlation coefficient and the Kruskal-Wallis test. The relationship between the thickness of the RGF and the covering of the SCC and patient age and gender was analyzed with the general linear model. RESULTS: Significant correlations were found between the presence of dehiscences and thickness of the bone overlying the SSC and RGF (P < .001). CONCLUSIONS: There is a morphologic relationship between the structure of the SSC and RGF.

Influencia de la existencia de una dehiscencia en un canal semicircular en el espesor óseo de los canales contralaterales / Effect of semicircular canal dehiscence on contralateral canal bone thickness

Objetivos: Determinar si la existencia de un canal semicircular superior o posterior dehiscente se asocia con el adelgazamiento de la cubierta ósea en el resto de los canales verticales (superior o posterior). Métodos: Se estudia mediante tomografía computarizada y se compara estadísticamente el espesor de los canales semicirculares superiores y posteriores contralaterales a una dehiscencia. Resultados: Cuando un canal semicircular superior presentaba una dehiscencia, el canal contralateral mostraba un adelgazamiento significativo de su espesor con una media de 0,5mm (DE:0,3mm). No sucede lo mismo con los posteriores que no modifican su grosor de 2,1mm (DE: 1,2mm; p=0,49).Cuando un canal semicircular posterior presentaba dehiscencia no se observó adelgazamiento significativo en los canales semicirculares superiores 1mm (DE:0,4), ni en el posterior contralateral 1,3mm (DE:0,3). Conclusión: La existencia de una dehiscencia del canal semicircular superior se asocia al adelgazamiento del hueso del canal del lado contrario, pero no de los canales semicirculares posteriores. No ocurre lo mismo si la dehiscencia es del canal semicircular posterior, que no altera de manera significativa el espesor del canal del lado contralateral ni en los superiores (AU)

Objectives: Our objective was to determine if the existence of dehiscence in the superior or posterior semicircular canal was associated with the thinning of the bone roof in the rest of the vertical canals (superior or posterior). Methods: The thickness of the superior and posterior semicircular canals contralateral to a dehiscence was studied using computerized tomography and compared statistically. Results: When a superior semicircular canal had a dehiscence, the contralateral canal showed a significant mean decrease in its thickness of 0.5mm (SD: 0.3mm). This was not the case if the dehiscence was in the posterior semicircular canal, where the thickness of 2.1 mm remained unchanged (SD: 1.2mm; P=0.49).When a posterior semicircular canal showed dehiscence, no significant thinning was shown in the superior semicircular (1mm; SD: 0.4) or in the posterior contralateral (1.3mm; SD: 0.3) canals. Conclusion: The existence of a dehiscence in the superior semicircular canal is associated with bone thinning in the canal on the opposite side, but not with the posterior semicircular canal. In contrast, if the dehiscence is in the posterior semicircular canal, contralateral and superior canal thickness is not modified (AU)

Effect of semicircular canal dehiscence on contralateral canal bone thickness.

OBJECTIVES: Our objective was to determine if the existence of dehiscence in the superior or posterior semicircular canal was associated with the thinning of the bone roof in the rest of the vertical canals (superior or posterior). METHODS: The thickness of the superior and posterior semicircular canals contralateral to a dehiscence was studied using computerized tomography and compared statistically. RESULTS: When a superior semicircular canal had a dehiscence, the contralateral canal showed a significant mean decrease in its thickness of 0.5mm (SD: 0.3 mm). This was not the case if the dehiscence was in the posterior semicircular canal, where the thickness of 2.1 mm remained unchanged (SD: 1.2 mm; P=.49). When a posterior semicircular canal showed dehiscence, no significant thinning was shown in the superior semicircular (1 mm; SD: 0.4) or in the posterior contralateral (1.3 mm; SD: 0.3) canals. CONCLUSION: The existence of a dehiscence in the superior semicircular canal is associated with bone thinning in the canal on the opposite side, but not with the posterior semicircular canal. In contrast, if the dehiscence is in the posterior semicircular canal, contralateral and superior canal thickness is not modified.

Influence of aging and menopause in the origin of the superior semicircular canal dehiscence.

OBJECTIVE: Determine if aging and menopause, known to be associated with bone resortion, also are associated with superior semicircular canal dehiscence. DESIGN: Observational study. SETTING: Study conducted in 3 tertiary Spanish hospitals. PATIENTS: Nonselected consecutive patients of all ages. INTERVENTIONS: Thin-section multi-detector row computed tomographic scan of the temporal bones. MAIN OUTCOME MEASURE: The minimum thickness of the bone covering the roof of the superior semicircular canal (SSC) measured in each temporal bone. The outcome was studied both as a continuous and as a dichotomous variable: thin (<0.6 mm) and normal (≥ 0.6 mm). RESULTS: Five hundred eighty-two ears of 312 patients were included in the study. Fifty-five percent of the sample were women. Patient's age ranged from 2 to 88 years. A 40-year age difference between ears was associated with a decreased thickness of bone covering the SSC of 0.10 mm, which is 10% of the average thickness of such bone. The thickness of the bone overlying the SSC of subjects younger than 45 years was an average of 1.14 mm (SD, 0.52 mm), whereas that of the subjects older than 45 years was equal to 1.02 mm (SD, 0.45 mm; p = 0.006). The percentage of ears with thin bone coverage of SSC was 7.1% in subjects younger than 45 years and 13.8% in those older than 45 years (p = 0.013). CONCLUSION: Our data support the hypothesis that there is a slight osteopenia of the roof of the superior semicircular canal associated with aging, and this effect seems to be more pronounced in menopausal women.

Left ventricular apical diseases.

There are many disorders that may involve the left ventricular (LV) apex; however, they are sometimes difficult to differentiate. In this setting cardiac imaging methods can provide the clue to obtaining the diagnosis. The purpose of this review is to illustrate the spectrum of diseases that most frequently affect the apex of the LV including Tako-Tsubo cardiomyopathy, LV aneurysms and pseudoaneurysms, apical diverticula, apical ventricular remodelling, apical hypertrophic cardiomyopathy, LV non-compaction, arrhythmogenic right ventricular dysplasia with LV involvement and LV false tendons, with an emphasis on the diagnostic criteria and imaging features. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s13244-011-0091-6) contains supplementary material, which is available to authorized users.

Recidiva vaginal e inguinal en una paciente con adenocarcinoma de endometrio temprano tratado por vía laparoscópica / Vaginal and inguinal recurrence in a patient with early endometrial adenocarcinoma treated with laparoscopic surgery

La cirugía es el tratamiento más adecuado para el adenocarcinoma (ACA) de endometrio en estadios tempranos, con lesiones confinadas al útero (estadios I/II).Aunque la vía laparotómica se utiliza todavía con gran frecuencia, la laparoscopia está progresando en gran medida para el tratamiento de estos tumores.Los resultados obtenidos en el tratamiento del ACA de endometrio por vía laparoscópica son excelentes, similares a la laparotomía, con costes parecidos y múltiples ventajas. Por todo ello, la laparoscopia está empezando a ser la vía preferida para muchos ginecólogos oncólogos.Presentamos a continuación un caso de ACA de endometrio, pT: Ib/G1, tratado por laparoscopia: histerectomía vaginal asistida por laparoscopia (HVAL)+doble anexectomía (DA)+citología (C)+linfadenectomía pélvica (LP) en el que se presentó una metástasis en introito vaginal a los 7 meses del tratamiento y otra inguinal a los 14 meses (AU)

Surgery is the optimal treatment for early-stage endometrial adenocarcinoma, with lesions confined to the uterus (stages I/II).Although laparotomy is still frequently employed, the use of laparoscopy to treat these tumors is increasing.The results obtained by laparoscopic surgery in the treatment of endometrial adenocarcinoma are excellent, similar to those of laparotomy, with multiple benefits and similar costs. Therefore, laparoscopy is becoming the preferred option for many gynecological oncologists.We report a case of endometrial carcinoma, pT: Ib/G1 treated by laparoscopy consisting of laparoscopic assisted vaginal hysterectomy+double annexectomy+cytology+pelvic lymphadenectomy, which progressed to vaginal introitus metastasis at 7 months of treatment and inguinal metastasis at 14 months (AU)