Differentiation of athlete's heart and hypertrophic cardiomyopathy by the fractal dimension of left ventricular trabeculae.

BACKGROUND: Differentiation between exercise induced adaptive myocardial hypertrophy (athlete's heart) and hypertrophic cardiomyopathy (HCM) is currently based on echocardiographic and cardiac magnetic resonance (CMR) criteria, but these may be insufficient in patients with subtle phenotype expression. This study aimed to assess whether left ventricular (LV) fractal pattern could permit to differentiate athlete's heart from HCM. METHODS: We recruited retrospectively 61 elite marathon runners, 67 patients with HCM, and 33 healthy subjects. A CMR study was performed in all subjects and the LV trabeculae fractal dimension (FD) was measured in end-diastolic frames of each short-axis cine sequence. For group comparison, the ratio of maximal myocardial wall thickness (mMWT)/indexed LV end-diastolic volume (LVED) was determined. RESULTS: As compared with athletes, patients with HCM had significantly (p < 0.001) greater FD in the LV basal (1.30 ± 0.07 vs. 1.23 ± 0.05) and apical (1.38 ± 0.06 vs. 1.30 ± 0.07) regions and in the whole heart (1.34 ± 0.05 vs. 1.27 ± 0.05). FD increased with age, left atrial area and indexed left ventricular mass (p < 0.05 for all) and correlated negatively with LV and RV end-diastolic volumes (p < 0.05 each). The addition of whole heart FD to the ratio of maximal myocardial wall thickness/indexed LVEDV lead to an improvement in the ability to discriminate HCM with a net reclassification index (NRI) of 71%. CONCLUSIONS: The FD regional distribution of the LV trabeculae differentiates patients with athlete's heart from patients with HCM. The addition of whole heart FD to the mMWT/indexed LVEDV ratio improves the predictive capacity of the model to differentiate both entities.

Biophysical and Lipidomic Biomarkers of Cardiac Remodeling Post-Myocardial Infarction in Humans.

Few studies have analyzed the potential of biophysical parameters as markers of cardiac remodeling post-myocardial infarction (MI), particularly in human hearts. Fourier transform infrared spectroscopy (FTIR) illustrates the overall changes in proteins, nucleic acids and lipids in a single signature. The aim of this work was to define the FTIR and lipidomic pattern for human left ventricular remodeling post-MI. A total of nine explanted hearts from ischemic cardiomyopathy patients were collected. Samples from the right ventricle (RV), left ventricle (LV) and infarcted left ventricle (LV INF) were subjected to biophysical (FTIR and differential scanning calorimetry, DSC) and lipidomic (liquid chromatography-high-resolution mass spectrometry, LC-HRMS) studies. FTIR evidenced deep alterations in the myofibers, extracellular matrix proteins, and the hydric response of the LV INF compared to the RV or LV from the same subject. The lipid and esterified lipid FTIR bands were enhanced in LV INF, and both lipid indicators were tightly and positively correlated with remodeling markers such as collagen, lactate, polysaccharides, and glycogen in these samples. Lipidomic analysis revealed an increase in several species of sphingomyelin (SM), hexosylceramide (HexCer), and cholesteryl esters combined with a decrease in glycerophospholipids in the infarcted tissue. Our results validate FTIR indicators and several species of lipids as useful markers of left ventricular remodeling post-MI in humans.

Plasma circular RNA hsa_circ_0001445 and coronary artery disease: Performance as a biomarker.

The role of circular RNAs (circRNAs) as biomarkers remains poorly characterized. Here, we investigated the performance of the circRNA hsa_circ_0001445 as a biomarker of coronary artery disease (CAD) in a real-world clinical practice setting. Plasma hsa_circ_0001445 was measured in a study population of 200 consecutive patients with suspected stable CAD who had undergone coronary computed tomographic angiography (CTA). Multivariable logistic models were constructed combining conventional risk factors with established biomarkers and hsa_circ_0001445. Model robustness was internally validated by the bootstrap technique. Biomarker accuracy was evaluated using the C-index. The integrated discrimination improvement (IDI) and net reclassification improvement (NRI) were also calculated. Risk groups were developed via classification tree models. The stability of plasma hsa_circ_0001445 was evaluated under different clinical conditions. hsa_circ_0001445 levels were associated with higher coronary atherosclerosis extent and severity with a 2-fold increase across tertiles (28.4%-50.0%). Levels of hsa_circ_0001445 were proportional to coronary atherosclerotic burden, even after comprehensive adjustment for cardiovascular risk factors, medications, and established biomarkers (fully adjusted OR = 0.432 for hsa_circ_0001445 as a continuous variable and fully adjusted OR = 0.277 for hsa_circ_0001445 as a binary variable). The classification of patients was improved with the incorporation of hsa_circ_0001445 into a base clinical model (CM) composed of conventional cardiovascular risk factors, showing an IDI of 0.047 and NRI of 0.482 for hsa_circ_0001445 as a continuous variable and an IDI of 0.056 and NRI of 0.373 for hsa_circ_0001445 as a binary variable. A trend toward higher discrimination capacity was also observed (C-indexCM  = 0.833, C-indexCM+continuous hsa_circ_0001445  = 0.856 and C-indexCM+binary hsa_circ_0001445  = 0.855). Detailed analysis of stability showed that hsa_circ_0001445 was present in plasma in a remarkably stable form. In vitro, hsa_circ_0001445 was downregulated in extracellular vesicles secreted by human coronary smooth muscle cells upon exposure to atherogenic conditions. In patients with suspected stable CAD referred for coronary CTA, plasma hsa_circ_0001445 improves the identification of coronary artery atherosclerosis.

Plasma microRNA Profiling Reveals Novel Biomarkers of Epicardial Adipose Tissue: A Multidetector Computed Tomography Study.

Epicardial adipose tissue (EAT) constitutes a novel parameter for cardiometabolic risk assessment and a target for therapy. Here, we evaluated for the first time the plasma microRNA (miRNA) profile as a source of biomarkers for epicardial fat volume (EFV). miRNAs were profiled in plasma samples from 180 patients whose EFV was quantified using multidetector computed tomography. In the screening study, 54 deregulated miRNAs were identified in patients with high EFV levels (highest tertile) compared with matched patients with low EFV levels (lowest tertile). After filtering, 12 miRNAs were selected for subsequent validation. In the validation study, miR-15b-3p, miR-22-3p, miR-148a-3p miR-148b-3p and miR-590-5p were directly associated with EFV, even after adjustment for confounding factors (p value < 0.05 for all models). The addition of miRNA combinations to a model based on clinical variables improved the discrimination (area under the receiver-operating-characteristic curve (AUC) from 0.721 to 0.787). miRNAs correctly reclassified a significant proportion of patients with an integrated discrimination improvement (IDI) index of 0.101 and a net reclassification improvement (NRI) index of 0.650. Decision tree models used miRNA combinations to improve their classification accuracy. These results were reproduced using two proposed clinical cutoffs for epicardial fat burden. Internal validation corroborated the robustness of the models. In conclusion, plasma miRNAs constitute novel biomarkers of epicardial fat burden.

Circulating microRNAs in suspected stable coronary artery disease: A coronary computed tomography angiography study.

OBJECTIVES: To explore the diagnostic performance of circulating microRNAs (miRNAs) as biomarkers in patients with suspected stable coronary artery disease (CAD). METHODS: Plasma samples were collected from 237 consecutive patients referred for coronary computed tomography angiography (CCTA). Presence, extension and severity of coronary stenosis were evaluated using the indexes: presence of diameter stenosis ≥ 50%, segment involvement score (SIS), segment stenosis score (SSS) and 3-vessel plaque score. A panel of 10 miRNAs previously associated with CAD was analysed using RT-qPCR. Multivariate analyses were used to analyse the associations between biomarkers and indexes. Discrimination was evaluated using the area under the ROC curve (AUC). Decision trees were generated using chi-squared Automatic Interaction Detector (CHAID) prediction models. RESULTS: After comprehensive adjustment including cardiovascular risk factors, medication use, confounding factors and protein-based biomarkers (hs-TnT and hs-CRP), several circulating miRNAs were inversely associated with coronary atherosclerosis extension (SIS and 3-vessel plaque score) and severity (SSS). In the whole population, circulating miRNAs showed a poor discrimination value for all indexes (AUC = 0.539-0.644) and did not increase the discrimination capacity of a clinical model of coronary stenosis presence, extension and severity based on conventional cardiovascular risk factors. Conversely, the inclusion of circulating miRNAs in decision trees produces models that improve the classification of cases and controls in specific patient subgroups. CONCLUSIONS: This study identifies a group of circulating miRNAs that failed to improve the discrimination capacity of cardiovascular risk factors but that has the potential to define specific subpopulations of patients with suspected stable CAD.

Associations between epicardial adipose tissue, subclinical atherosclerosis and high-density lipoprotein composition in type 1 diabetes.

BACKGROUND: The pathophysiology of cardiovascular complications in people with type 1 diabetes (T1DM) remains unclear. An increase in epicardial adipose tissue (EAT) and alterations in the composition of high-density lipoprotein (HDL) are associated with coronary artery disease, but information on its relationship in T1DM is very limited. Our aim was to determine the association between EAT volume, subclinical atherosclerosis, and HDL composition in type 1 diabetes. METHODS: Seventy-two long-term patients with T1DM without clinical atherosclerosis were analyzed. EAT volume and subclinical atherosclerosis were measured using cardiac computed tomography angiography. EAT was adjusted according to body surface to obtain an EAT index (iEAT). HDL composition was determined. RESULTS: The mean iEAT was 40.47 ± 22.18 cc/m2. The bivariate analysis showed positive associations of the iEAT with gender, age, hypertension, dyslipidemia, smoking, body mass index, waist circumference, insulin dose, and triglyceride (P < 0.05). The iEAT correlated positively with small HDL, increased content of apolipoprotein (apo)A-II and apoC-III, and decreased content of apoE and free cholesterol. Multiple linear regression showed that age, apoA-II content in HDL, and waist circumference were independently associated with the iEAT. Fifty percent of the patients presented subclinical atherosclerotic lesions. These patients had a higher iEAT, and their HDL contained less cholesterol and more apoA-II and lipoprotein-associated phospholipase A2 than patients without subclinical atherosclerosis. CONCLUSION: Alterations in the composition of HDL in TIDM are associated with increased iEAT and the presence of subclinical atherosclerosis. We propose that these abnormalities of HDL composition could be useful to identify T1DM patients at highest cardiovascular risk.

High-Sensitivity Troponin T and Soluble Form of AXL as Long-Term Prognostic Biomarkers after Heart Transplantation.

ANTECEDENTS: Cardiac allograft vasculopathy (CAV) is a frequent complication limiting the long-term (>1 year) survival after heart transplantation (HTx). CAV is initiated by endothelial dysfunction and can lead to severe cardiovascular (CV) complications. Since CAV is often clinically silent, biomarkers could help identifying HTx patients at risk of CAV and their severe complications. AIM: Evaluate the clinical yield of high-sensitivity cardiac troponin T (hs-cTnT), marker of cardiomyocyte damage, and the soluble form of AXL (sAXL), biomarker of endothelial dysfunction, to assess the prognosis of long-term cardiovascular (CV) events occurring after HTx. METHODS: 96 patients were evaluated at least > 1 year after HTx. CAV was evaluated by coronary angiography or multisliced tomography, and hs-cTnT and sAXL measured 6 months before or after CAV evaluation. Patients were followed during 42 ± 15 months for a combined end point including cardiac death, angina or acute myocardial infarction, left ventricular ejection fraction < 50%, or heart failure not due to an acute rejection. RESULTS: 51 patients (53%) presented CAV at evaluation; 21 of them had CV events. Hs-cTnT (56 ± 45 versus 20 ± 18 ng/L; p = 0.04) and sAXL concentrations (98 ± 51 versus 26 ± 26 ng/L; p = 0.01) were significantly higher in patients with CV events. Hs-cTnT (HR 1.03; 95% CI 1.015-1.042, p = 0.0001) and sAXL (HR 1.01; 95% CI 1.001-1.019, p = 0.02) were independent predictors of CV events. A hs-cTnT concentration < 21 ng/L, detected by AUC ROC, predicted the absence of CV events with a predictive value of 91%; sAXL did not add more predictive value to hs-cTnT. Survival free of CV events was 92% in patients with hs-cTnT < 21 ng/L and 57% in those with hs-cTnT > 21 ng/L (p < 0.001). CONCLUSION: Hs-cTnT, but not sAXL, measured during the long-term follow-up of HTx patients appears as a helpful biomarker to identify patients at low risk of adverse CV outcomes.

Identification of new biophysical markers for pathological ventricular remodelling in tachycardia-induced dilated cardiomyopathy.

Our aim was to identify biophysical biomarkers of ventricular remodelling in tachycardia-induced dilated cardiomyopathy (DCM). Our study includes healthy controls (N = 7) and DCM pigs (N = 10). Molecular analysis showed global myocardial metabolic abnormalities, some of them related to myocardial hibernation in failing hearts, supporting the translationality of our model to study cardiac remodelling in dilated cardiomyopathy. Histological analysis showed unorganized and agglomerated collagen accumulation in the dilated ventricles and a higher percentage of fibrosis in the right (RV) than in the left (LV) ventricle (P = .016). The Fourier Transform Infrared Spectroscopy (FTIR) 1st and 2nd indicators, which are markers of the myofiber/collagen ratio, were reduced in dilated hearts, with the 1st indicator reduced by 45% and 53% in the RV and LV, respectively, and the 2nd indicator reduced by 25% in the RV. The 3rd FTIR indicator, a marker of the carbohydrate/lipid ratio, was up-regulated in the right and left dilated ventricles but to a greater extent in the RV (2.60-fold vs 1.61-fold, P = .049). Differential scanning calorimetry (DSC) showed a depression of the freezable water melting point in DCM ventricles - indicating structural changes in the tissue architecture - and lower protein stability. Our results suggest that the 1st, 2nd and 3rd FTIR indicators are useful markers of cardiac remodelling. Moreover, the 2nd and 3rd FITR indicators, which are altered to a greater extent in the right ventricle, are associated with greater fibrosis.

Translating the microRNA signature of microvesicles derived from human coronary artery smooth muscle cells in patients with familial hypercholesterolemia and coronary artery disease.

AIMS: To analyze the impact of atherogenic lipoproteins on the miRNA signature of microvesicles derived from human coronary artery smooth muscle cells (CASMC) and to translate these results to familial hypercholesterolemia (FH) and coronary artery disease (CAD) patients. METHODS: Conditioned media was collected after exposure of CASMC to atherogenic lipoproteins. Plasma samples were collected from two independent populations of diagnosed FH patients and matched normocholesterolemic controls (Study population 1, N=50; Study population 2, N=24) and a population of patients with suspected CAD (Study population 3, N=50). Extracellular vesicles were isolated and characterized using standard techniques. A panel of 30 miRNAs related to vascular smooth muscle cell (VSMC) (patho-)physiology was analyzed using RT-qPCR. RESULTS: Atherogenic lipoproteins significantly reduced levels of miR-15b-5p, -24-3p, -29b-3p, -130a-3p, -143-3p, -146a-3p, -222-3p, -663a levels (P<0.050) in microvesicles (0.1µm-1µm in diameter) released by CASMC. Two of these miRNAs, miR-24-3p and miR-130a-3p, were reduced in circulating microvesicles from FH patients compared with normocholesterolemic controls in a pilot study (Study population 1) and in different validation studies (Study populations 1 and 2) (P<0.050). Supporting these results, plasma levels of miR-24-3p and miR-130a-3p were also downregulated in FH patients compared to controls (P<0.050). In addition, plasma levels of miR-130a-3p were inversely associated with coronary atherosclerosis in a cohort of suspected CAD patients (Study population 3) (P<0.050). CONCLUSIONS: Exposure to atherogenic lipoproteins modifies the miRNA profile of CASMC-derived microvesicles and these alterations are reflected in patients with FH. Circulating miR-130a-3p emerges as a potential biomarker for coronary atherosclerosis.

Cystatin-C and epicardial adipose tissue as noninvasive predictors of cardiovascular risk in acromegaly.

BACKGROUND: Acromegaly (ACRO) is associated with elevated cardiovascular risk, although the prevalence of coronary artery disease (CAD) is unclear. Increased epicardial adipose tissue (EAT) and elevated cystatin-C (Cys-C) levels are cardiovascular risk factors, also related to the progression of CAD in several populations. AIMS: To measure the severity and extent of CAD in patients with ACRO and to determine whether either EAT or Cys-C reflect higher cardiovascular risk in patients with ACRO than in healthy controls. SUBJECTS AND METHODS: Case-control study, of 35 patients with ACRO (19 males, 17 with active disease) and 35 age-, gender- and body mass index (BMI)-matched healthy controls; mean age was 48·1 ± 8·1 years and mean BMI was 27·6 ± 4·8 kg/m2 . Cys-C was measured by an immunoturbidimetric assay. The 10-year risk of developing a coronary event was calculated using the Framingham Risk Score (FRS). EAT index (volume indexed to body surface area), and severity and extent of CAD were measured using a 256-slice multidetector computed tomography scanner (iCT-256 Philips Healthcare, Amsterdam). RESULTS: Coronary artery disease lesions, EAT index and severity/extent of CAD were similar between patients with ACRO and controls. Forty-four per cent of patients with ACRO had mild coronary lesions associated with greater EAT index (ß = 0·022, P = 0·036). Cys-C levels correlated with both EAT index (ρ = 0·386, P = 0·031) and FRS (ρ = 0·477, P = 0·004) in patients with ACRO only, despite similar prevalence of traditional cardiovascular risk factors. In a multiple linear regression model, both Cys-C levels (ß = 0·369, P = 0·007) and EAT index (ß = 0·29, P = 0·025) predicted FRS (R2 = 0·613). CONCLUSIONS: In patients with ACRO, both Cys-C and EAT index might be used as noninvasive predictors of cardiovascular risk.

Seudoaneurisma en injerto aortocoronario de vena safena / Saphenous venous graft pseudoaneurysm

No disponible

Troponina T de alta sensibilidad y angiotomografía computarizada coronaria para el diagnóstico rápido del dolor torácico en el servicio de urgencias / High-sensitivity troponin T testing and coronary computed tomography angiography for rapid diagnosis of chest pain in the emergency department

Objetivo: Determinar la probabilidad de encontrar lesiones coronarias significativas, el tiempo diagnóstico y la seguridad de una nueva estrategia basada en la utilización de troponina T de alta sensibilidad (TnT-as) seguida de angiotomografía computarizada coronaria (ATCC) en pacientes con dolor torácico de posible origen coronario, en comparación con la atención clínica habitual en un servicio de urgencias (SU). Método: Ensayo clínico diagnóstico aleatorizado y abierto realizado en un SU de un hospital terciario universitario entre febrero 2011 y abril 2013. Se incluyó a pacientes atendidos por dolor torácico con electrocardiograma no diagnóstico en urgencias. Se asignó de forma aleatorizada a la estrategia nueva (EN) (seriación de TnT-as seguida de ATCC cuando fue negativa) o la estrategia convencional (EC) (seriación de TnT de cuarta generación seguida de ergometría cuando fue negativa). Se indicó coronariografía invasiva si las troponinas, la ATCC o la ergometría fueron positivas. Se registró el resultado de la coronariografía invasiva, el tiempo diagnóstico y la aparición de un evento adverso (muerte por cualquier causa, nuevo infarto de miocardio, nueva angina inestable o necesidad de revascularización) durante los 3 meses de seguimiento. Resultados: De los 102 pacientes aleatorizados se excluyeron 7. Se incluyeron 95 pacientes, 45 asignados a la EC y 50 a la EN. La coronariografía mostró lesiones significativas en un 92,9% de los casos de la EN y en un 66,7% de la EC. La proporción de pacientes diagnosticados en las primeras 6 horas fue mayor en la EN en comparación con la EC (20,0% vs 4,4%; p = 0,023). Durante el periodo de 3 meses de seguimiento, se registró una muerte en la EN y ningún evento en la EC. Conclusiones: La EN podría aportar un diagnóstico más rápido, así como una mayor probabilidad de encontrar lesiones coronarias significativas, sin diferencias en la aparición de eventos adversos en los 3 primeros meses. Estos hallazgos necesitan ser confirmados en futuros estudios con mayor número de pacientes (AU)

Objective: To determine the probability of finding significant coronary lesions, the time to diagnosis, and the safety of a new diagnostic approach based on high-sensitivity cardiac troponin T (hsTnT) testing followed by coronary computed tomography angiography (CCTA) in patients with chest pain of possible coronary origin. The method was compared with our hospital emergency department’s standard practice. Methods: Unblinded randomized controlled trial in a tertiary level university hospital between February 2011 and April 2013. We included emergency patients with chest pain and nondiagnostic electrocardiographic findings. Patients were assigned randomly to the new approach (hsTnT assay, followed by CCTA if the assay findings were negative) or the conventional approach (fourth generation TnT assay and, if negative, followed by an exercise stress test). Invasive coronary angiography was ordered in all patients if the results of either troponin assay, the CCTA, or the stress test were positive. We recorded the results of angiography, time until diagnosis, and all-cause mortality, new myocardial infarction, new unstable angina, or need for revascularization within the next 3 months. Results: Of 102 patients randomized, 7 were excluded; 50 of the remaining 95 patients were assigned to the new strategy, and 45 to the conventional approach. Coronary angiography demonstrated significant lesions in 92.9% of the patients treated with the new strategy and 66.7% of those diagnosed conventionally. A higher percentage of patients were diagnosed within 6 hours with the new approach (20.0% vs 4.4% of conventional-approach patients, P = .023). During the 3 months following diagnosis, 1 death occurred in the intervention group and none in the conventional-approach group. Conclusions: The new strategy could accelerate diagnosis and increase the probability of finding significant coronary lesions, but we found no significant differences in adverse events in the 3 months following diagnosis. These findings should be confirmed in studies with larger numbers of patients (AU)

[High-sensitivity troponin T testing and coronary computed tomography angiography for rapid diagnosis of chest pain in the emergency department]. / Troponina T de alta sensibilidad y angiotomografía computarizada coronaria para el diagnóstico rápido del dolor torácico en el servicio de urgencias.

OBJECTIVES: To determine the probability of finding significant coronary lesions, the time to diagnosis, and the safety of a new diagnostic approach based on high-sensitivity cardiac troponin T (hsTnT) testing followed by coronary computed tomography angiography (CCTA) in patients with chest pain of possible coronary origin. The method was compared with our hospital emergency department's standard practice. MATERIAL AND METHODS: Unblinded randomized controlled trial in a tertiary level university hospital between February 2011 and April 2013. We included emergency patients with chest pain and nondiagnostic electrocardiographic findings. Patients were assigned randomly to the new approach (hsTnT assay, followed by CCTA if the assay findings were negative) or the conventional approach (fourth generation TnT assay and, if negative, followed by an exercise stress test). Invasive coronary angiography was ordered in all patients if the results of either troponin assay, the CCTA, or the stress test were positive. We recorded the results of angiography, time until diagnosis, and all-cause mortality, new myocardial infarction, new unstable angina, or need for revascularization within the next 3 months. RESULTS: Of 102 patients randomized, 7 were excluded; 50 of the remaining 95 patients were assigned to the new strategy, and 45 to the conventional approach. Coronary angiography demonstrated significant lesions in 92.9% of the patients treated with the new strategy and 66.7% of those diagnosed conventionally. A higher percentage of patients were diagnosed within 6 hours with the new approach (20.0% vs 4.4% of conventional-approach patients, P = .023). During the 3 months following diagnosis, 1 death occurred in the intervention group and none in the conventional-approach group. CONCLUSION: The new strategy could accelerate diagnosis and increase the probability of finding significant coronary lesions, but we found no significant differences in adverse events in the 3 months following diagnosis. These findings should be confirmed in studies with larger numbers of patients.

OBJETIVO: Determinar la probabilidad de encontrar lesiones coronarias significativas, el tiempo diagnóstico y la seguridad de una nueva estrategia basada en la utilización de troponina T de alta sensibilidad (TnT-as) seguida de angiotomografía computarizada coronaria (ATCC) en pacientes con dolor torácico de posible origen coronario, en comparación con la atención clínica habitual en un servicio de urgencias (SU). METODO: Ensayo clínico diagnóstico aleatorizado y abierto realizado en un SU de un hospital terciario universitario entre febrero 2011 y abril 2013. Se incluyó a pacientes atendidos por dolor torácico con electrocardiograma no diagnóstico en urgencias. Se asignó de forma aleatorizada a la estrategia nueva (EN) (seriación de TnT-as seguida de ATCC cuando fue negativa) o la estrategia convencional (EC) (seriación de TnT de cuarta generación seguida de ergometría cuando fue negativa). Se indicó coronariografía invasiva si las troponinas, la ATCC o la ergometría fueron positivas. Se registró el resultado de la coronariografía invasiva, el tiempo diagnóstico y la aparición de un evento adverso (muerte por cualquier causa, nuevo infarto de miocardio, nueva angina inestable o necesidad de revascularización) durante los 3 meses de seguimiento. RESULTADOS: De los 102 pacientes aleatorizados se excluyeron 7. Se incluyeron 95 pacientes, 45 asignados a la EC y 50 a la EN. La coronariografía mostró lesiones significativas en un 92,9% de los casos de la EN y en un 66,7% de la EC. La proporción de pacientes diagnosticados en las primeras 6 horas fue mayor en la EN en comparación con la EC (20,0% vs 4,4%; p = 0,023). Durante el periodo de 3 meses de seguimiento, se registró una muerte en la EN y ningún evento en la EC. CONCLUSIONES: La EN podría aportar un diagnóstico más rápido, así como una mayor probabilidad de encontrar lesiones coronarias significativas, sin diferencias en la aparición de eventos adversos en los 3 primeros meses. Estos hallazgos necesitan ser confirmados en futuros estudios con mayor número de pacientes.

Reliability of a new method for coronary artery calcium or metal subtraction by 320-row cardiac CT.

PURPOSE: To investigate the feasibility and diagnostic accuracy of subtraction CTA on patients with highly calcified coronary artery disease (CAD) or previous implanted stents, in comparison with invasive coronary angiography (ICA). MATERIALS AND METHODS: Twenty-three patients were recruited. All conventional and subtraction CTA exams were performed using a 320-row CT. Subjective image quality score was assessed for each segment using a 4-point scale: 1-uninterpretable to 4-good image quality. RESULTS: A total of 129 calcified or stented coronary segments were studied. Mean coronary image quality with conventional CTA was 2.73 ± 0.97 and in subtracted CTA 3.3 ± 0.92 (p < 0.01). After metal subtraction, image quality in stented coronary segments with >3 mm of diameter improved from 2.69 ± 0.97 to 3.34 ± 0.89 (p = 0.01) and in those with <3 mm of diameter from 2.11 ± 0.78 to 2.67 ± 0.87 (p = 0.17). There was an improvement in diagnostic accuracy to detect ICA stenosis >50 % by subtraction CTA compared with conventional CTA (AUC 0.93 to 0.87; p = 0.02). CONCLUSION: Subtraction CTA is promising in overcoming limitations of conventional CTA due to calcium or metal artefacts, especially if no motion artefact is present or when stents > 3 mm are studied. KEY POINTS: • Calcium and metal artefacts are still a limitation for conventional coronary CTA • Diagnostic accuracy is improved by subtraction as compared with conventional CTA • Subtraction CTA is a promising tool to overcome limitations of conventional CTA.

Chest CT examinations in patients presenting with acute chest pain: a pictorial review.

Acute chest pain (ACP) is one of the most common presenting symptoms at the emergency department. The differential diagnosis is vast. To exclude life-threatening causes, radiologists encounter an increasing amount of thoracic computed tomography (CT) examinations including CT angiography of the heart and great vessels. The dual- and triple-rule CT examinations are currently implemented in clinical practice. We retrospectively identified chest CT examinations in the setting of acute chest pain in our hospitals and collected a variety of common and uncommon cases. In this pictorial essay, we present the most educative cases from patients who presented with acute chest pain in the emergency department of our hospitals and for whom a thoracic CT was ordered. When aortic emergencies, acute coronary syndrome, and pulmonary embolism are excluded, these cases may help the radiologist to suggest alternative diagnoses in the diagnostic challenge of acute chest pain. Teaching Points • The number of chest CT examinations for ACP is increasing.• Chest CT examinations may help suggesting alternative diagnosis in ACP.• Radiologists should be aware of the differential diagnosis of ACP.

Soluble TNFα-receptor 1 as a predictor of coronary calcifications in patients after long-term cure of Cushing's syndrome.

PURPOSE: Increased cardiovascular (CV) risk persists in Cushing's syndrome (CS), despite remission of hypercortisolism. The aim of this study was to evaluate prevalence of coronary artery disease in CS patients and its correlation with classical CV risk factors and inflammatory markers. METHODS: Cardiac multidetector computed tomography (MDCT) was performed in 41 patients (7 men, 31 of pituitary origin, 29 cured, mean age: 48.6 ± 13 years), using 64-slice Toshiba Aquilion systems. Coronary atherosclerotic plaques were detected and coronary calcifications quantified by the Agatston score (AS). Clinical and biochemical parameters were correlated with the AS to identify possible surrogate markers of coronary disease. Normal values for clinical and biochemical parameters were obtained from a gender- and age-matched normal reference population (n = 82). RESULTS: CS patients with calcifications (AS > 0) (N = 13, 32%) had higher levels of sTNF-R1, homocysteine, triglycerides, blood pressure and body mass index than patients without calcifications (AS = 0) and those of normal reference population. Both groups of CS patients (AS > 0 and AS = 0) had elevated trunk fat mass and IL-6 compared to reference values. Patients with AS > 0 had less adiponectin and higher insulin, HOMA and fibrinogen than those found in normal reference population. sTNF-R1 correlated positively with AS and remained significant after adjusting for confounding factors. The same result was observed when we considered only cured CS patients. CONCLUSION: In our cohort of CS patients sTNF-R1 was a predictor of coronary calcifications. Since MDCT is an expensive technique not readily available in daily clinical practice, increased sTNF-R1 could be a marker of CV risk even in cured CS.