Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and maintained diagnostic accuracy: comparison of results with cardiac catheterization in a head-to-head pilot investigation.

BACKGROUND: Noninvasive coronary angiography with the use of multislice computed tomography (CT) scanners is feasible with high sensitivity and negative predictive value; however, the radiation exposure associated with this technique is rather high. We evaluated coronary angiography using whole-heart 320-row CT, which avoids exposure-intensive overscanning and overranging. METHODS AND RESULTS: A total of 30 consecutive patients with suspected coronary artery disease referred for clinically indicated conventional coronary angiography (CCA) were included in this prospective intention-to-diagnose study. CT was performed with the use of up to 320 simultaneous detector rows before same-day CCA, which, together with quantitative analysis, served as the reference standard. The per-patient sensitivity and specificity for CT compared with CCA were 100% (95% confidence interval [CI], 72 to 100) and 94% (95% CI, 73 to 100), respectively. Per-vessel versus per-segment sensitivity and specificity were 89% (95% CI, 62 to 98) and 96% (95% CI, 90 to 99) versus 78% (95% CI, 56 to 91) and 98% (95% CI, 96 to 99), respectively. Interobserver agreement between the 2 readers was significantly better for CCA (97% of 121 coronary arteries) than for CT (90%; P=0.04). Percent diameter stenosis determined with the use of CT showed good correlation with CCA (P<0.001, R=0.81) without significant underestimation or overestimation (-3.1+/-24.4%; P=0.08). Intraindividual comparison of CT with CCA revealed a significantly smaller effective radiation dose (median, 4.2 versus 8.5 mSv; P<0.05) and amount of contrast agent required (median, 80 versus 111 mL; P<0.001) for 320-row CT. The majority of patients (87%) indicated that they would prefer CT over CCA for future diagnostic imaging (P<0.001). CONCLUSIONS: CT with the use of emerging technology has the potential to significantly reduce the radiation dose and amount of contrast agent required compared with CCA while maintaining high diagnostic accuracy.

A randomized placebo-controlled study on the effect of nifedipine on coronary endothelial function and plaque formation in patients with coronary artery disease: the ENCORE II study.

AIMS: Endothelial dysfunction and plaque formation are features of atherosclerosis. Inhibition of L-type calcium channels or HMG-CoA pathway improves endothelial function and reduces plaque size. Thus, we investigated in stable coronary artery disease (CAD) the effects of a calcium antagonist on coronary endothelial function and plaque size. METHODS AND RESULTS: In 454 patients undergoing PCI, acetylcholine (10(-6) to 10(-4) M) was infused in a coronary segment without significant CAD. Changes in coronary diameter were measured and an intravascular ultrasound examination (IVUS) was performed. On top of statin therapy, patients were randomized in a double-blind fashion to placebo or nifedipine GITS 30-60 mg/day and followed for 18-24 months. Blood pressure was lower on nifedipine than on placebo by 5.8/2.1 mmHg (P < 0.001) as was total and LDL cholesterol (4.8 mg/dL; P = 0.495), while HDL was higher (3.6 mg/dL; P = 0.026). In the most constricting segment, nifedipine reduced vasoconstriction to acetylcholine (14.0% vs. placebo 7.7%; P < 0.0088). The percentage change in plaque volume with nifedipine and placebo, respectively, was 1.0 and 1.9%, ns. CONCLUSION: The ENCORE II trial demonstrates in a multi-centre setting that calcium channel blockade with nifedipine for up to 2 years improves coronary endothelial function on top of statin treatment, but did not show an effect of nifedipine on plaque volume.

Treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter.

BACKGROUND: Treatment of coronary in-stent restenosis is hampered by a high incidence of recurrent in-stent restenosis. We assessed the efficacy and safety of a paclitaxel-coated balloon in this setting. METHODS: We enrolled 52 patients with in-stent restenosis in a randomized, double-blind, multicenter trial to compare the effects of a balloon catheter coated with paclitaxel (3 microg per square millimeter of balloon surface area) with those of an uncoated balloon catheter in coronary angioplasty. The primary end point was late luminal loss as seen on angiography. Secondary end points included the rates of restenosis (a binary variable) and major adverse cardiac events. RESULTS: Multivessel disease was present in 80% of patients in both groups. Quantitative coronary angiography revealed no significant differences in baseline measures. At 6 months, angiography showed that the mean (+/-SD) in-segment late luminal loss was 0.74+/-0.86 mm in the uncoated-balloon group versus 0.03+/-0.48 mm in the coated-balloon group (P=0.002). A total of 10 of 23 patients (43%) in the uncoated-balloon group had restenosis, as compared with 1 of 22 patients (5%) in the coated-balloon group (P=0.002). At 12 months, the rate of major adverse cardiac events was 31% in the uncoated-balloon group and 4% in the coated-balloon group (P=0.01). This difference was primarily due to the need for target-lesion revascularization in six patients in the uncoated-balloon group (P=0.02). CONCLUSIONS: Treatment of coronary in-stent restenosis with paclitaxel-coated balloon catheters significantly reduced the incidence of restenosis. These data suggest that the inhibition of restenosis by local drug delivery may not require stent implantation and sustained drug release at the site of injury. (ClinicalTrials.gov number, NCT00106587 [ClinicalTrials.gov].).

Is there a gender difference in noninvasive coronary imaging? Multislice computed tomography for noninvasive detection of coronary stenoses.

BACKGROUND: Multislice computed tomography (MSCT) coronary angiography is the foremost alternative to invasive coronary angiography. METHODS: We sought to compare the diagnostic accuracy of MSCT in female and male patients with suspected coronary disease. Altogether 50 women and 95 men underwent MSCT with 0.5 mm detector collimation. Coronary artery stenoses of at least 50% on conventional coronary angiography were considered significant. RESULTS: The coronary vessel diameters of all four main coronary artery branches were significantly larger in men than in women. The diagnostic accuracy of MSCT in identifying patients with coronary artery disease was significantly lower for women (72%) compared with men (89%, p < 0.05). Also sensitivity (70% vs. 95%), positive predictive value (64% vs. 93%), and the rate of nondiagnostic examinations (14% vs. 4%, all: p < 0.05) were significantly worse for women. The effective radiation dose of MSCT coronary angiography was significantly higher in the examination of women (13.7 +/- 1.2 mSv) than of men (11.7 +/- 0.9 mSv, p < 0.001), mainly as a result of the fact that the radiosensitive female breast (contributing 24.5% of the dose in women) is in the x-ray path. CONCLUSION: Noninvasive coronary angiography with MSCT might be less accurate and sensitive for women than men. Also, women are exposed to a significantly higher effective radiation dose than men.

CT coronary angiography: influence of different cardiac reconstruction intervals on image quality and diagnostic accuracy.

PURPOSE: To prospectively analyze image quality and diagnostic accuracy of different reconstruction intervals of coronary angiography using multislice computed tomography (MSCT). MATERIALS AND METHODS: For each of 47 patients, 10 ECG-gated MSCT reconstructions were generated throughout the RR interval from 0 to 90%, resulting in altogether 470 datasets. These datasets were randomly analyzed for image quality and accuracy and compared with conventional angiography. Statistical comparison of intervals was performed using nonparametric analysis for repeated measurements to account for clustering of arteries within patients. RESULTS: Image reconstruction intervals centered at 80, 70, and 40% of the RR interval resulted (in that order) in the best overall image quality for all four main coronary vessels. Eighty percent reconstructions also yielded the highest diagnostic accuracy of all intervals. The combination of the three best intervals (80, 70, and 40%) significantly reduced the nondiagnostic rate as compared with 80% alone (p=0.005). However, the optimal reconstruction interval combination achieved significantly improved specificities and nondiagnostic rates (p<0.05). The optimal combination consisted of 1.7+/-0.9 reconstruction intervals on average. In approximately half of the patients (49%, 23/47) a single reconstruction was optimal. In 18 (38%), 3 (6%), and 3 (6%) patients one, two, and three additional reconstruction intervals were required, respectively, to achieve optimal quality. In 28% of the patients the optimal combination consisted of reconstructions other than the three best intervals (80, 70, and 40%). CONCLUSION: Multiple image reconstruction intervals are essential to ensure high image quality and accuracy of CT coronary angiography.

Interventricular septum hematoma during cineventriculography.

BACKGROUND: Intraseptal hematoma and subsequent myocardial infarction due to accidental contrast agent deposition complicating diagnostic cineventriculography is a previously undescribed complication of angiography. CASE PRESENTATION: A 61 year old man was admitted at intensive care unit because of unstable angina pectoris 1 hour after coronary angiography. Transthoracic contrast echocardiography showed a non-perfused area in the middle of interventricular septum with an increase of thickening up to 26 mm. Review of cineventriculography revealed contrast enhancement in the interventricular septum after contrast medium injection and a dislocation of the pigtail catheter tip. Follow up by echocardiography and MRI showed, that intramural hematoma has resolved after 6 weeks. After 8 weeks successful stent implantation in LAD was performed and after 6 month the patient had a normal LV-function without ischemic signs or septal thickening demonstrated by stressechocardiography. CONCLUSION: A safe and mobile position of the pigtail catheter during ventriculography in the middle of the LV cavity should be ensured to avoid this potentially life-threatening complication. For assessment and absolute measurement of intramural hematoma contrast-enhanced echocardiography is more feasible than MRI and makes interchangeable results.

Coronary artery stenosis quantification using multislice computed tomography.

RATIONALE AND OBJECTIVES: Reliable noninvasive detection of stenoses with multislice computed tomography (MSCT) is feasible. This study's aim was to analyze the agreement, correlation, and reliability of MSCT with conventional coronary angiography as the reference standard for quantification of coronary artery stenoses. MATERIALS AND METHODS: A total of 118 significant (at least 50%) coronary artery stenoses with a reference vessel diameter of at least 1.5 mm in 62 patients were analyzed by MSCT using 16 detector rows (Aquilion, Toshiba, Otawara, Japan), multisegment reconstruction, and voxel sizes of 0.35x0.35x0.5 mm. The degree of stenosis on MSCT and quantitative coronary angiography (QCA) was measured by correlating the difference between the reference vessel diameter (average of 2 measurements directly proximal and distal to the stenosis) and the stenotic vessel diameter to the reference vessel diameter. RESULTS: Correlation between the percent diameter stenosis determined by MSCT (78.2+/-13.6%) and QCA (76.0+/-14.8%) was significant (P<0.001) but only moderately so (R=0.51). Bland-Altman analysis revealed no systematic under- or overestimation with MSCT but large limits of agreements (+/-27.6%). Also the limits of agreement for interobserver agreement (reliability) of MSCT data were considerably large (+/-24.8%). Among the 27 coronary artery stenoses with a reference diameter of at least 3.5 mm, there was improved correlation (R=0.80) and the limits of agreement between MSCT and QCA were significantly smaller (+/-17.3%, P<0.008). The agreement between MSCT and QCA was not significantly different for stenoses with no calcification or only calcium spots (+/-28.2%) as compared with those with moderate-or-severe calcifications (+/-27.3%; P=0.8). MSCT allowed correct classification of coronary stenoses into low-grade (below 75%) and high-grade stenoses (at least 75%), in 62% (73 of 118). CONCLUSIONS: The accuracy and reliability of coronary artery stenosis quantification with MSCT using isotropic voxel sizes and multisegment reconstruction is still too low to recommend routine clinical application because of rather low agreement, correlation, and reliability. Despite these limitations, the current results demonstrate the potential of MSCT for reliable and accurate quantification of coronary artery stenoses in the near future provided that further improvements in spatial and temporal resolution will be achieved.

Noninvasive detection of coronary artery stenoses with multislice computed tomography or magnetic resonance imaging.

BACKGROUND: Multislice computed tomography (CT) and magnetic resonance imaging (MRI) are the main candidates for noninvasive coronary angiography; however, multislice CT, unlike MRI, exposes patients to radiation and an iodinated intravenous contrast agent. OBJECTIVE: To compare the diagnostic accuracy of multislice CT and MRI for noninvasive detection of clinically significant coronary stenoses (> or =50%). DESIGN: Prospective intention-to-diagnose study. SETTING: Single tertiary referral center, Berlin, Germany. PATIENTS: 129 consecutive patients with suspected coronary artery disease. INTERVENTIONS: Multislice CT and MRI were both performed within a median of 1 day before conventional coronary angiography, which served as the reference standard. MEASUREMENTS: Diagnostic performance of multislice CT and MRI. RESULTS: 129 patients completed the study. Altogether, 108 patients with 430 vessels could be examined with both multislice CT and MRI and were used for analysis. In the per-patient analysis, the sensitivity of multislice CT (92% [95% CI, 82% to 96%]) was significantly higher than that of MRI (74% [CI, 61% to 83%]; P = 0.013). The sensitivity for detecting clinically significant stenoses was 82% for multislice CT and 54% for MRI (P < 0.001). Specificity and negative predictive value of multislice CT and MRI in the per-vessel analysis were 90% versus 87% (P = 0.73) and 95% versus 90% (P = 0.032), respectively. The effective radiation dose used with multislice CT (mean, 12.3 mSv [SD, 1.4]) in a consecutive subgroup of 73 patients was not significantly different from that used with diagnostic cardiac catheterization (11.4 mSv [SD, 4.8]) (P = 0.169). Most patients (74%) indicated that they would prefer multislice CT for future diagnostic imaging (P < 0.001). LIMITATIONS: This was a single-center study with 129 patients. CONCLUSIONS: In patients referred for conventional coronary angiography, multislice CT compares favorably with MRI for noninvasive detection of coronary stenoses.

Clinical and angiographic analysis with a cobalt alloy coronary stent (driver) in stable and unstable angina pectoris.

The Clinical and Angiographic analysis with a Cobalt Alloy Coronary Stent (Driver) (CLASS) study was a prospective, nonrandomized, multicenter study designed to assess the safety and efficacy of a cobalt-chromium alloy-based stent in patients with stable or unstable angina pectoris. A total of 203 lesions were treated in 202 enrolled patients. The percentage of major adverse cardiac event-free patients was 87.6% (177 of 202) at 6 months (primary safety end point; major adverse cardiac events were defined as death, myocardial infarction, emergency bypass surgery, or target lesion revascularization [percutaneous transluminal coronary angioplasty or coronary artery bypass grafting]). The angiographic success rate (primary efficacy end point) was 100%, and the procedural success rate was 98%. The binary in-stent restenosis rate at 6 months was 12.6%. Our results have demonstrated that the Driver cobalt-chromium alloy stent can be used with a low 6-month incidence of major adverse cardiac events, a low 6-month binary restenosis rate, and high angiographic and procedural success rates.

The Emergency Medical Care of Patients With Acute Myocardial Infarction.

BACKGROUND: Optimizing the emergency medical care chain might shorten the time to treatment of patients with ST-elevation myocardial infarction (STEMI). The initial care by a physician, and, in particular, correct ECG interpretation, are critically important factors. METHODS: From 1999 onward, data on the care of patients with myocardial infarction have been recorded and analyzed in the Berlin Myocardial Infarction Registry. In the First Medical Contact Study, data on initial emergency medical care were obtained on 1038 patients who had been initially treated by emergency physicians in 2012. Their pre-hospital ECGs were re-evaluated in a blinded fashion according to the criteria of the European Society of Cardiology. RESULTS: The retrospective re-evaluation of pre-hospital ECGs revealed that 756 of the 1038 patients had sustained a STEMI. The emergency physicians had correctly diagnosed STEMI in 472 patients (62.4%), and they had correctly diagnosed ventricular fibrillation in 85 patients (11.2%); in 199 patients (26.3%), the ECG interpretation was unclear. The pre-hospital ECG interpretation was significantly associated with the site of initial hospitalization and the ensuing times to treatment. In particular, the time from hospital admission to cardiac catheterization was longer in patients with an unclear initial ECG interpretation than in those with correctly diagnosed STEMI (121 [54; 705] vs. 36 [19; 60] minutes, p <0.001). After multivariate adjustment, this corresponded to a hazard ratio* of 2.67 [2.21; 3.24]. CONCLUSION: Pre-hospital ECG interpretation in patients with STEMI was a trigger factor with a major influence on the time to treatment in the hospital. The considerable percentage of pre-hospital ECGs whose interpretation was unclear implies that there is much room for improvement.

Vascular responses at proximal and distal edges of paclitaxel-eluting stents: serial intravascular ultrasound analysis from the TAXUS II trial.

BACKGROUND: On the basis of brachytherapy experience, edge stenosis has been raised as a potential limitation for drug-eluting stents. We used serial intravascular ultrasound (IVUS) to prospectively analyze vessel responses in adjacent reference segments after implantation of polymer-controlled paclitaxel-eluting stents. METHODS AND RESULTS: TAXUS II was a randomized, double-blind trial with 2 consecutive patient cohorts that compared slow-release (SR) and moderate-release (MR) paclitaxel-eluting stents with control bare metal stents (BMS). By protocol, all patients had postprocedure and 6-month follow-up IVUS. Quantitative IVUS analysis was performed by an independent core laboratory, blinded to treatment allocation, in 5-mm vessel segments immediately proximal and distal to the stent. Serial IVUS was available for 106 SR, 107 MR, and 214 BMS patients. For all 3 groups, a significant decrease in proximal-edge lumen area was observed at 6 months. The decrease was comparable (by ANOVA, P=0.194) for patients in the SR (-0.54+/-2.1 mm2) and MR (-0.88+/-1.9 mm2) groups compared with the BMS (-1.02+/-1.9 mm2) group. For the distal edge, a significant decrease in lumen area was only observed with BMS (-0.91+/-2.0 mm2, P<0.0001); this decrease was significantly attenuated with SR (0.08+/-2.0 mm2) and MR (-0.19+/-1.7 mm2) stents (P<0.0001 by ANOVA). Negative vessel remodeling was observed at the proximal (-0.48+/-2.2 mm2, P=0.011) but not the distal edges of BMS and at neither edge of SR or MR stents. CONCLUSIONS: The marked reduction in in-stent restenosis with SR or MR stents is not associated with increased edge stenosis at 6-month follow-up IVUS. In fact, compared with BMS, there is instead a significant reduction in late lumen loss at the distal edge with TAXUS stents.

Lack of clopidogrel pretreatment effect on the relative efficacy of bivalirudin with provisional glycoprotein IIb/IIIa blockade compared to heparin with routine glycoprotein IIb/IIIa blockade: a REPLACE-2 substudy.

OBJECTIVES: The purpose of this study was to assess if clopidogrel pretreatment affects the relative efficacy of bivalirudin versus heparin with glycoprotein (GP) IIb/IIIa blockade for percutaneous coronary interventions (PCI). BACKGROUND: Although thienopyridine pretreatment may improve clinical outcomes with PCI, it is unknown if bivalirudin's efficacy compared with heparin is dependent upon such pretreatment. METHODS: The Randomized Evaluation in Percutaneous coronary intervention Linking Angiomax to reduced Clinical Events (REPLACE-2) trial was a double-blind, triple-dummy, randomized-controlled trial comparing heparin plus routine GP IIb/IIIa blockade (heparin group) with bivalirudin plus provisional GP IIb/IIIa blockade (bivalirudin group) during PCI. The primary end point was a composite of death, myocardial infarction (MI), urgent revascularization at 30 days, and major in-hospital bleeding. The secondary end point was a 30-day composite of death, MI, and urgent revascularization. Clopidogrel pretreatment was encouraged (300 mg loading, 75 mg/day). RESULTS: Of 6,010 patients enrolled, 5,893 received clopidogrel, with 85.8% in the bivalirudin and 84.6% in the heparin group receiving clopidogrel pretreatment. Bivalirudin (provisional GP IIb/IIIa blockade 7.2%) was noninferior to the heparin group for both primary and secondary end points. Clopidogrel pretreatment did not affect the relative efficacy of bivalirudin versus heparin with GP IIb/IIIa blockade, irrespective of pretreatment duration. Pretreatment was associated with significantly lower primary end point with bivalirudin (8.7% pretreatment vs. 12.9% no pretreatment, p = 0.007), and nonsignificantly with heparin (9.7% vs. 11.7%, respectively, p = 0.20). Multivariable models showed a trend toward lower primary and secondary end points with clopidogrel pretreatment. CONCLUSIONS: Clopidogrel pretreatment at the doses and time administered in this trial did not influence the relative efficacy of bivalirudin versus heparin plus GP IIb/IIIa blockade for PCI. However, pretreatment was associated with a trend towards lower clinical events after PCI.

Direct stenting versus direct stenting followed by centered beta-radiation with intravascular ultrasound-guided dosimetry and long-term anti-platelet treatment: results of a randomized trial: Beta-Radiation Investigation with Direct Stenting and Galileo in Europe (BRIDGE).

OBJECTIVES: We sought to assess the efficacy of vascular brachytherapy (VBT) combined with stenting for the primary prevention of restenosis. BACKGROUND: Intravascular brachytherapy after stent implantation for de novo lesions has been abandoned for the present. We revisited this procedure by optimizing all procedural steps-the use of glycoprotein IIb/IIa blockers, direct stenting, adequate radiation coverage, avoidance of edge damage, source centering, intravascular ultrasound-guided dosimetry, and continuation of a dual anti-platelet regimen for one year. METHODS: The Beta-Radiation Investigation with Direct stenting and Galileo in Europe (BRIDGE) study is a multicenter, randomized controlled trial evaluating the long-term efficacy of VBT with P-32 (20 Gy at 1 mm in the coronary wall) after direct stenting. The primary end point was angiographic intra-stent late loss; secondary end points were six months binary restenosis and neo-intimal hyperplasia. Patients (n = 112) with de novo lesions (2.5 to 4.0 mm in diameter up to 15 mm long) were randomized to either VBT or no-VBT. RESULTS: At six months, intra-stent loss was 0.43 and 0.84 mm (p < 0.001) in the irradiated and control groups, respectively. Intra-stent neo-intimal volume was reduced from 36 mm3 to 10 mm3. However, in the irradiated group there were six late occlusions as well as eight restenoses outside the stented and peri-stented area at the fall-off dose edges of the irradiated area. Accordingly, the target vessel revascularization and major adverse cardiac and cerebrovascular events rates at one year in the VBT group (20.4% and 25.9%, respectively) were higher than in the control group (12.1% and 17.2%, respectively). CONCLUSIONS: Despite the optimization of pre-, peri-, and post-procedural factors and despite the relative efficacy of the brachytherapy for the prevention of the intra-stent neo-intimal hyperplasia, the clinical outcome of the irradiated group was less favorable than that of the control group.

A randomized comparison of the value of additional stenting after optimal balloon angioplasty for long coronary lesions: final results of the additional value of NIR stents for treatment of long coronary lesions (ADVANCE) study.

OBJECTIVES: We sought to investigate the clinical benefit of additional stent implantation after achieving an optimal result of balloon angioplasty (BA) in long coronary lesions (>20 mm). BACKGROUND: Long coronary lesions are associated with increased early complications and late restenosis after BA. Stenting improves the early outcome, but stent restenosis is also related to both lesion length and stent length. METHODS: A total of 437 patients with a single native lesion 20 to 50 mm in length were included and underwent BA, using long balloons matched to lesion length and vessel diameter (balloon/artery ratio 1.1) to achieve a diameter stenosis (DS) <30% by on-line quantitative coronary angiography (QCA). "Bail-out stenting" was performed for flow-limiting dissections or >50% DS. Patients in whom an optimal BA result was achieved were randomized to additional stenting (using NIR stents) or no stenting. The primary end point was freedom from major adverse cardiac events (MACE) at nine months, and core laboratory QCA was performed on serial angiograms. RESULTS: Bailout stenting was necessary in 149 patients (34%) and was associated with a significantly increased risk of peri-procedural infarction (p < 0.02). Among the 288 randomized patients, the mean lesion length was 27+/-9 mm, and the vessel diameter was 2.78+/-0.52 mm. The procedural success rate was 90% for the 143 patients assigned to BA alone (control group), as compared with 93% in the 145 patients assigned to additional stenting (stent group), which resulted in a superior early minimal lumen diameter (0.54 mm, p < 0.001) and led to reduced angiographic restenosis (27% vs. 42%, p = 0.022). Freedom from MACE at nine months was 77% in both groups. CONCLUSIONS: A strategy of provisional stenting for long coronary lesions led to bailout stenting in one-third of patients, with a threefold increase in peri-procedural infarction. Additional stenting yielded a lower angiographic restenosis rate, but no reduction in MACE at nine months.

Long-term fluvastatin reduces the hazardous effect of renal impairment on four-year atherosclerotic outcomes (a LIPS substudy).

Mild renal impairment is an important risk factor for late cardiovascular complications. This substudy of the Lescol Intervention Prevention Study (LIPS) assessed the effect of fluvastatin on outcome of patients who had renal dysfunction and those who did not. Complete data for creatinine clearance calculation (Cockcroft-Gault formula) were available for 1,558 patients (92.9% of the LIPS population). Patients were randomized to fluvastatin or placebo after successful completion of a first percutaneous coronary intervention. Follow-up time was 3 to 4 years. The effect of baseline creatinine clearance on coronary atherosclerotic events (cardiac death, nonfatal myocardial infarction, and coronary reinterventions not related to restenosis) was evaluated. Baseline creatinine clearance (logarithmic transformation) was inversely associated with an incidence of adverse events among patients who received placebo (hazard ratio 0.99, 95% confidence interval 0.982 to 0.998, p = 0.01). However, no association was noted between creatinine clearance and the incidence of adverse events among patients who received fluvastatin (hazard ratio 1.0, 95% confidence interval 0.99 to 1.0, p = 0.63). No further deterioration in creatinine clearance was observed during follow-up, regardless of baseline renal function or allocated treatment. Occurrence of adverse events was not related to changes in renal function during follow-up. Fluvastatin therapy markedly decreased the risk of coronary atherosclerotic events after percutaneous intervention in patients who had lower values of creatinine clearance at baseline. The benefit of fluvastatin was unrelated to any effect on renal function.

Multisegment and halfscan reconstruction of 16-slice computed tomography for detection of coronary artery stenoses.

RATIONALE AND OBJECTIVES: To compare the diagnostic accuracy and image quality of 2 reconstruction algorithms (multisegment and halfscan) for computed tomography (CT) coronary angiography in patients without beta-blocker medication. MATERIALS AND METHODS: Thirty-four patients with 42 significant coronary stenoses in 136 main coronary branches were examined using a 16-slice CT scanner (Aquilion, Toshiba, Otawara, Japan). Twenty-seven patients (79%) had heart rates above 65 beats/min. RESULTS: Without exclusion of branches the sensitivity, specificity, accuracy, and rate of nonassessable segments with multisegment versus halfscan reconstruction were 88 versus 74%, 91 versus 71%, 90 versus 72%, and 2 versus 21% (P < 0.01), respectively. Multisegment reconstruction improved the average vessel length free of motion artifacts by 56% compared with halfscan reconstruction (P < 0.01). Image quality in terms of vessel continuity and visibility of side branches (P < 0.005) was significantly better using multisegment reconstruction. CONCLUSIONS: Multisegment reconstruction has superior diagnostic accuracy and image quality compared with halfscan reconstruction in patients with normal heart rates.

Does contrast echocardiography with Optison induce myocardial necrosis in humans?

Myocardial contrast echocardiography is a promising diagnostic tool for detecting microvascular integrity. Multiple experimental laboratories have shown that diagnostic combined microbubble contrast and ultrasound exposure can cause vessel rupture and myocardial damage in laboratory animals. This study investigated the phenomenon of contrast ultrasonically induced myocardial damage in human beings. Twenty consecutive patients (mean age of 60 +/- 12 years, 14 men) underwent contrast echocardiography with intravenous Optison using a mechanical index of at least 1.4 (Vivid Five System (GE, Vingmed Ultrasound, Horton, Norway). Creatine kinase (CK), creatine kinase-isoenzyme MB (CK-MB); CK-MB mass, myoglobin, and troponin I were measured before and 2, 4, 8, and 24 hours after contrast echocardiography. There was no significant correlation concerning the response to contrast echocardiography for any pair of parameters at any time after the intervention. Only in 2 patients were there higher values for troponin I before and after contrast echocardiography without an increase of myoglobin, CK, or CK-MB mass and activity. These values were therefore interpreted as false positive because of renal failure and severe heart failure. The use of contrast echocardiography is without demonstrated risk of myocardial damage even in patients with different cardiologic entities.

Apical tissue tracking echocardiography for characterization of regional left ventricular function: comparison with magnetic resonance imaging in patients after myocardial infarction.

OBJECTIVE: The purpose of this study was to characterize the normal pattern of apical tracking and to investigate whether tissue tracking imaging is more useful for evaluation of regional left-ventricular function than noncontrast harmonic echocardiography in patients after myocardial infarction. BACKGROUND: Left ventricular longitudinal shortening plays an important role in cardiac contraction, and can be evaluated online by a new Doppler tissue imaging method. METHODS: We included 40 healthy participants and 40 patients after myocardial infarction. They underwent tissue tracking imaging and noncontrast harmonic imaging by an experienced and an inexperienced observer. Diagnostic accuracy of semiquantitative evaluation of left ventricular function was compared using magnetic resonance imaging as reference method. RESULTS: Velocity-time integrals decreased from basal to apical segments in healthy participants. Tissue tracking imaging has a higher diagnostic sensitivity than noncontrast imaging for the diagnosis of regional wall-motion abnormalities (expert, 78% vs 97%, P <.01; beginner, 63% vs 91%, P <.001), whereas specificity remained unchanged (expert, 99% vs 97%, not significant; beginner, 91% vs 92%, not significant). CONCLUSIONS: Tissue tracking imaging is feasible and evaluates regional systolic myocardial function quantitatively with high diagnostic accuracy compared with magnetic resonance imaging in patients after myocardial infarction, and is more accurate than noncontrast harmonic echocardiography.

Atypical vessels as an early sign of intracardiac myxoma?

We report on a woman with previously unknown left atrial myxoma, who underwent percutaneous coronary intervention. 45 months after the initial coronary angiography, echocardiography demonstrated a large atrial myxoma, which was not seen echocardiographically before. The retrospective analysis of the pre-intervention coronary angiography revealed atypical vessels in the atrial septum, which are interpreted as early signs of myxoma.