Browsing by Subject "Coronary Angiography"

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    ItemOpen Access
    Clinical and angiographic outcomes with everolimus eluting stents for the treatment of cardiac allograft vasculopathy.
    (Journal of interventional cardiology, 2014-02) Azarbal, Babak; Arbit, Boris; Ramaraj, Radhakrishnan; Kittleson, Michelle; Young, Amelia; Czer, Lawrence; Rafiei, Matthew; Currier, Jesse; Makkar, Raj; Kobashigawa, Jon
    OBJECTIVES: This study aimed to examine clinical efficacy, safety, and intermediate clinical outcomes with everolimus-eluting stents (EESs) in patients with transplant coronary artery disease (TCAD). BACKGROUND: TCAD is a major cause of mortality in patients following orthotopic heart transplantation (OHT). Systemic everolimus in OHT patients has been shown to reduce TCAD. The safety and efficacy of an EES, the Xience V, have not been evaluated in this population. METHODS: Patients post-OHT with hemodynamically significant CAD who underwent percutaneous coronary intervention (PCI) with EES were included. Participants were maintained on dual antiplatelet therapy for 1-year post-PCI. We examined procedural success, in-hospital and 1-year mortality, stent thrombosis, angiographic restenosis, and myocardial infarction rates. All patients had follow-up angiography 1-year after PCI. Target vessel revascularization (TVR), target lesion revascularization (TLR), in-segment restenosis, target vessel failure (TVF), and lumen late loss were noted. RESULTS: PCI was performed in 34 de novo lesions in 21 patients, and 40 EES were placed. Procedural success rate was 100%. Average stent was 16.5 ± 5.1 mm long and 3.0 ± 0.6 mm in diameter. All patients had angiographic follow-up (409 ± 201 days). There was no stent thrombosis, deaths, or myocardial infarctions during follow-up. Two patients had focal in-stent restenosis. TLR rate was 5.9% (2/34), and TVR rate was 11.1% (3/27). Quantitative coronary angiography (QCA) showed stenosis diameter to be 19.98 ± 17.57%. CONCLUSIONS: Use of an EES is associated with a low incidence of TVR and TLR in patients with TCAD. Further studies are needed to determine whether PCI with EES changes long-term outcomes.
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    Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease.
    (Annals of internal medicine, 2016-07) Mark, Daniel B; Federspiel, Jerome J; Cowper, Patricia A; Anstrom, Kevin J; Hoffmann, Udo; Patel, Manesh R; Davidson-Ray, Linda; Daniels, Melanie R; Cooper, Lawton S; Knight, J David; Lee, Kerry L; Douglas, Pamela S; PROMISE Investigators

    Background

    PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) found that initial use of at least 64-slice multidetector computed tomography angiography (CTA) versus functional diagnostic testing strategies did not improve clinical outcomes in stable symptomatic patients with suspected coronary artery disease (CAD) requiring noninvasive testing.

    Objective

    To conduct an economic analysis for PROMISE (a major secondary aim of the study).

    Design

    Prospective economic study from the U.S. perspective. Comparisons were made according to the intention-to-treat principle, and CIs were calculated using bootstrap methods. (ClinicalTrials.gov: NCT01174550).

    Setting

    190 U.S. centers.

    Patients

    9649 U.S. patients enrolled in PROMISE between July 2010 and September 2013. Median follow-up was 25 months.

    Measurements

    Technical costs of the initial (outpatient) testing strategy were estimated from Premier Research Database data. Hospital-based costs were estimated using hospital bills and Medicare cost-charge ratios. Physician fees were taken from the Medicare Physician Fee Schedule. Costs were expressed in 2014 U.S. dollars, discounted at 3% annually, and estimated out to 3 years using inverse probability weighting methods.

    Results

    The mean initial testing costs were $174 for exercise electrocardiography; $404 for CTA; $501 to $514 for pharmacologic and exercise stress echocardiography, respectively; and $946 to $1132 for exercise and pharmacologic stress nuclear testing, respectively. Mean costs at 90 days were $2494 for the CTA strategy versus $2240 for the functional strategy (mean difference, $254 [95% CI, -$634 to $906]). The difference was associated with more revascularizations and catheterizations (4.25 per 100 patients) with CTA use. After 90 days, the mean cost difference between the groups out to 3 years remained small.

    Limitation

    Cost weights for test strategies were obtained from sources outside PROMISE.

    Conclusion

    Computed tomography angiography and functional diagnostic testing strategies in patients with suspected CAD have similar costs through 3 years of follow-up.

    Primary funding source

    National Heart, Lung, and Blood Institute.
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    Fibroblast growth factor 23 is not associated with and does not induce arterial calcification.
    (Kidney international, 2013-06) Scialla, Julia J; Lau, Wei Ling; Reilly, Muredach P; Isakova, Tamara; Yang, Hsueh-Ying; Crouthamel, Matthew H; Chavkin, Nicholas W; Rahman, Mahboob; Wahl, Patricia; Amaral, Ansel P; Hamano, Takayuki; Master, Stephen R; Nessel, Lisa; Chai, Boyang; Xie, Dawei; Kallem, Radhakrishna R; Chen, Jing; Lash, James P; Kusek, John W; Budoff, Matthew J; Giachelli, Cecilia M; Wolf, Myles; Chronic Renal Insufficiency Cohort Study Investigators
    Elevated fibroblast growth factor 23 (FGF23) is associated with cardiovascular disease in patients with chronic kidney disease. As a potential mediating mechanism, FGF23 induces left ventricular hypertrophy; however, its role in arterial calcification is less clear. In order to study this, we quantified coronary artery and thoracic aorta calcium by computed tomography in 1501 patients from the Chronic Renal Insufficiency Cohort (CRIC) study within a median of 376 days (interquartile range 331-420 days) of baseline. Baseline plasma FGF23 was not associated with the prevalence or severity of coronary artery calcium after multivariable adjustment. In contrast, higher serum phosphate levels were associated with prevalence and severity of coronary artery calcium, even after adjustment for FGF23. Neither FGF23 nor serum phosphate were consistently associated with thoracic aorta calcium. We could not detect mRNA expression of FGF23 or its coreceptor, klotho, in human or mouse vascular smooth muscle cells, or normal or calcified mouse aorta. Whereas elevated phosphate concentrations induced calcification in vitro, FGF23 had no effect on phosphate uptake or phosphate-induced calcification regardless of phosphate concentration or even in the presence of soluble klotho. Thus, in contrast to serum phosphate, FGF23 is not associated with arterial calcification and does not promote calcification experimentally. Hence, phosphate and FGF23 promote cardiovascular disease through distinct mechanisms.
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    Geographic variation and trends in carotid imaging among medicare beneficiaries, 2001 to 2006.
    (Circulation. Cardiovascular quality and outcomes, 2010-11) Curtis, LH; Greiner, MA; Patel, MR; Duncan, PW; Schulman, KA; Matchar, DB

    Background

    Diagnostic imaging among Medicare beneficiaries is an important contributor to rising health care costs. We examined temporal trends and geographic variation in the use of carotid ultrasound, carotid magnetic resonance angiography (MRA), and carotid x-ray angiography.

    Methods and results

    Analysis of a 5% national sample of claims from the Centers for Medicare and Medicaid Services for 1999 through 2006. Patients were 65 years or older and underwent carotid ultrasound, carotid MRA, carotid x-ray angiography, or a carotid intervention. The main outcome measures were annual age-adjusted rates of carotid imaging and interventions and factors associated with the use of carotid imaging. Rates of imaging increased by 27%, from 98.2 per 1000 person-years in 2001 to 124.3 per 1000 in 2006. Rates of carotid ultrasound increased by 23%, and rates of MRA increased by 66%. Carotid intervention rates decreased from 3.6 per 1000 person-years in 2001 to 3.1 per 1000 person-years in 2006. In 2006, rates of carotid ultrasound were lowest in the New England, Mountain, and West North Central regions and highest in the Middle Atlantic and South Atlantic regions. Regional differences persisted after adjustment for patient demographic characteristics, history of vascular disease and other comorbid conditions, and study year.

    Conclusions

    From 2001 through 2006, there was substantial growth and variation in the use of carotid imaging, including a marked increase in the use of MRA, and a decrease in the overall rate of carotid intervention.
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    Impact of beta-blockade premedication on image quality of ECG-gated thoracic aorta CT angiography.
    (Acta radiologica (Stockholm, Sweden : 1987), 2014-12) Entezari, Pegah; Collins, Jeremy; Chalian, Hamid; Tore, Huseyin Gurkan; Carr, James; Yaghmai, Vahid
    BACKGROUND: Thoracic aortic aneurysm is one of the most common aorta pathologies worldwide, which is commonly evaluated by computed tomography angiography (CTA). One of the routine methods to improve the image quality of CTA is heart rate reduction prior to study by beta-blockade administration. PURPOSE: To assess the effect of beta-blockade on image quality of the ascending aorta in electrocardiography (ECG)-gated dual-source CTA (DSCTA) images. MATERIAL AND METHODS: In this retrospective study, ECG-gated thoracic aorta CTA images of 40 patients without beta-blocker administration were compared with ECG-gated images of 40 patients with beta-blockade. Images of the aorta were analyzed objectively and subjectively at three levels: sinus of Valsalva (sinus), sinotubular junction (STJ), and mid ascending aorta (MAA). Quantitative sharpness index (SI) and signal-to-noise ratio (SNR) were calculated and two radiologists evaluated the image quality using a 3-point scale. RESULTS: Mean heart rate in beta-blocker and non-beta-blocker groups was 61.7 beats per minute (bpm) (range, 58.1-63.9 bpm) and 72.9 bpm (range, 69.3-84.1 bpm), respectively (P < 0.05). Aorta wall SI, SNR, and subjective grading were comparable between the two groups at all three levels (P > 0.05). CONCLUSION: Beta-blocker premedication may not be necessary for imaging of ascending aorta with ECG-gated DSCTA.
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    Impact of fibrinogen levels on angiographic progression and 12-year survival in the armed forces regression study.
    (Angiology, 2010-05) Devendra, Ganesh P; Hart, Stephen A; Whitney, Edwin J; Krasuski, Richard A
    We assessed the role of fibrinogen levels on angiographic progression and long-term survival among 111 patients with coronary disease enrolled in the Armed Forces Regression Study (AFREGS). Baseline fibrinogen levels and quantitative coronary angiography were performed initially and at 30 months. Progression or nonregression of coronary disease was more prevalent in patients with high fibrinogen than patients with normal fibrinogen (66.1% vs 45.5%; P = .022). Twelve-year cardiovascular (CV) mortality was substantially higher if fibrinogen was elevated (17.9% vs 3.6%, P = .016). Among patients with elevated fibrinogen and angiographic progression or nonregression, there were 10 deaths and all were CV. Elevated levels of fibrinogen predict the angiographic progression of existing coronary disease and likelihood of CV death. Among patients with elevated levels of fibrinogen, angiographic progression identifies a significantly increased likelihood of a fatal CV event.
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    Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization.
    (J Am Heart Assoc, 2016-03-14) Hess, Connie N; Hellkamp, Anne S; Roe, Matthew T; Thomas, Laine; Scirica, Benjamin M; Peng, S Andrew; Peterson, Eric D; Wang, Tracy Y
    BACKGROUND: While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non-ST-segment elevation myocardial infarction patients who did not undergo coronary revascularization. METHODS AND RESULTS: We included unrevascularized non-ST-segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry-GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease (CAD; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD. Two-year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all-cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability-weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD, and 34.7% (n=4915) had angiography with CAD. Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI]: 0.99 [0.93-1.06]), angiography without CAD (1.04 [0.74-1.47]), and angiography with CAD (1.12 [1.00-1.25], Pinteraction=0.20). CONCLUSIONS: We found no association between discharge clopidogrel use and long-term risk of major adverse cardiac events among older, unrevascularized non-ST-segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.
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    Utility of observation units for young emergency department chest pain patients.
    (Journal of Emergency Medicine, 2013-02) Ely, Sora; Chandra, Abhinav; Mani, Giselle; Drake, Weiying; Freeman, Debbie; Limkakeng, Alexander T
    BACKGROUND: Determining which patients presenting to the Emergency Department (ED) require further work-up for acute coronary syndrome (ACS) can be difficult. The utility of routine observation for cardiac testing in low-risk young adult patients has been questioned. STUDY OBJECTIVES: We investigated the rate of positive findings yielded by routine cardiac observation unit work-up in patients aged 40 years or younger. METHODS: This was a retrospective observational cohort study of patients aged 18-40 years who were evaluated for ACS in an ED-based observation unit. Data were collected by trained abstractors from electronic medical records. RESULTS: A total of 362 patients met inclusion criteria. Of those, 239 received stress testing, yielding five positive and nine indeterminate results. One other patient had acute troponin elevation while under observation. The positive stress test patients and troponin-elevated patient underwent cardiac angiography. Only one positive stress test patient showed significant coronary stenosis and received coronary interventions. In follow-up data, one patient had an adverse cardiac outcome within 1 year of index visit, but no coronary interventions. Thus, only 3 patients had adverse cardiac events, with only one patient warranting intervention discovered by observation unit stress testing and a second via serial cardiac markers. CONCLUSION: Routine observation of symptomatic young adults for ACS had low yield. Observation identified one patient with acute cardiac marker elevation and further stress testing identified only one patient with intervenable ACS, despite a high false-positive rate. This suggests that observation and stress testing should not be routinely performed in this demographic absent other high-risk features.
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    Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study.
    (American heart journal, 2015-12) Meyers, H Pendell; Limkakeng, Alexander T; Jaffa, Elias J; Patel, Anjni; Theiling, B Jason; Rezaie, Salim R; Stewart, Todd; Zhuang, Cassandra; Pera, Vijaya K; Smith, Stephen W
    The modified Sgarbossa criteria were proposed in a derivation study to be superior to the original criteria for diagnosing acute coronary occlusion (ACO) in left bundle branch block (LBBB). The new rule replaces the third criterion (5 mm of excessively discordant ST elevation [STE]) with a proportion (at least 1 mm STE and STE/S wave ≤-0.25). We sought to validate the modified criteria.This retrospective case-control study was performed by chart review in 2 tertiary care center emergency departments (EDs) and 1 regional referral center. A billing database was used at 1 site to identify all ED patients with LBBB and ischemic symptoms between May 2009 and June 2012. In addition, all 3 sites identified LBBB ACO patients who underwent emergent catheterization. We measured QRS amplitude and J-point deviation in all leads, blinded to outcomes. Acute coronary occlusion was determined by angiographic findings and cardiac biomarker levels, which were collected blinded to electrocardiograms. Diagnostic statistics of each rule were calculated and compared using McNemar's test.Our consecutive cohort search identified 258 patients: 9 had ACO, and 249 were controls. Among the 3 sites, an additional 36 cases of ACO were identified, for a total of 45 ACO cases and 249 controls. The modified criteria were significantly more sensitive than the original weighted criteria (80% vs 49%, P < .001) and unweighted criteria (80% vs 56%, P < .001). Specificity of the modified criteria was not statistically different from the original weighted criteria (99% vs 100%, P = .5) but was significantly greater than the original unweighted criteria (99% vs 94%, P = .004).The modified Sgarbossa criteria were superior to the original criteria for identifying ACO in LBBB.