Role of coronary angiogram before transcatheter aortic valve implantation

BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.

Is There Still a Place for Post-Resuscitation Electrocardiogram for Therapeutic Management and Coronary Angiogram Indication after Out-of-Hospital Cardiac Arrest?

Out-of-hospital cardiac arrest is a common cause of death. Some therapeutic strategies performed daily are still debated, including particularly emergency coronary angiography independently of the clinical pattern. Primary percutaneous coronary intervention seems the strategy of choice in ST-segment elevation myocardial infarction but in other clinical presentations, benefit of coronary angiogram remains controversial. To improve management of out-of-hospital cardiac arrest and define the best timing to perform coronary angiogram, we suggest a study design based on ECG evaluation to define predictors of coronary artery disease after resuscitated cardiac arrest by distinguishing 3 groups according to ECG after resuscitation: ST segment elevation and LBBB;repolarisation disorder or no repolarisation disorder. Evaluation of ECG changes may still be useful as a triage method for establishing the indication for emergency coronary angiogram due to easy, non invasive and quick method and thus for limiting complications associated with this exam in acute phase.

The coronary computed tomography angiogram: from the basics to advanced interpretation

Introduction According to the WHO's World Health Report 2003, 1cardiovascular disease was responsible for 16.7 million deaths annually. As a result, it is now the leading cause of death in developed countries and in many developing countries. Detecting and preventing the progression of coronary artery disease is the target of many pharmaceutical, technological and other scientific programs today. Presently, the main diagnostic tool for evaluating coronary arteries is thc conventional coronary angiogram (CCA).……

Obstructive sleep apnea is associated with severity and long-term prognosis of acute coronary syndrome

Background Obstructive sleep apnea （OSA） is a common disease in patients with acute coronary syndrome （ACS） and associated with an increased risk of fatal and nonfatal cardiovascular events. However, most patients in previous study were treated with bare metal stents and the sample sizes were relatively low. The goal of this study was to evaluate the influence of OSA on the severity and prognosis of patients admitted for ACS. Methods In this prospective cohort study, we enrolled patients with ACS who were hospitalized for coronary angiogram/percutaneous coronary intervention and undergone polysomnography. We divided the patients into two groups： moderate to severe OSA group [apnea-hypopnea index （AHI） 〉 15 events/h] and control group （AHI ≤ 15 events/h）. They were followed up for up 32 months. Then, we compared the ACS severity and long-term major adverse cardiovascular events （MACE） in patients with different severity of OSA. Results Five hundred and twenty nine patients were included in the final analysis, with 76% of them being men and an average age of 59 ＋ 10 years. The overall mean AHI is 29 ± 19 events/h, 70.5% of them （373/529） being with moderate to severe OSA and 29.5% （156/529） assign into control group. Compared with controls, patients with moderate or severe OSA exhibited a higher prevalence of hypertension as well as higher body mass index, SYNTAX score, Epworth score and length of hospitalization. With a median follow-up duration of 30 months, accumulative rate of MACE was also higher in patients with moderate or severe OSA than that in the control group （8.6% vs. 3.2%, P = 0.028）. After adjusting for baseline confounders by cox regression model, moderate to severe OSA was an independent risk factor of long-term MACE （P = 0.047, HR = 1.618, 95% CI： 1.069-3.869）. Conclusions The results of this study demonstrate that moderate or severe OSA is correlated with disease severity and associated with worse long-term prognosis in ACS patients. The results raising the possibility that early diagnose and interventions of OSA could improve long-term outcomes in ACS patients.

Highly sensitive troponin I assay in the diagnosis of coronary artery disease in patients with suspected stable angina

BACKGROUND Evaluation of suspected stable angina patients with probable coronary artery disease(CAD)in the community is challenging.In the United Kingdom,patients with suspected stable angina are referred by community physicians to be assessed by specialists within the hospital system in rapid access chest pain clinics(RACPC).The role of a highly sensitive troponin I(uscTnI)assay in the diagnosis of suspected CAD in a RACPC in a“real-life”setting in a non-academic hospital has not been explored.AIM To examine the diagnostic value of uscTnI(detection limit 0.12 ng/L,upper reference range 8.15 ng/L,and detected uscTnI in 96.8%of the reference population),in the evaluation of stable CAD in a non-selected patient group,with several co-morbidities,who presented to the RACPC.METHODS One hundred and seventy two RACPC patients were assigned to either functional or anatomical testing according to the hospital protocol.RESULTS The investigations offered to patients were exercise tolerance test 7.6%,24 h ECG 1.2%,Echocardiogram 14.5%,stress echocardiogram 8.1%,coronary computed tomography angiography(CCTA)12.8%,coronary angiogram 13.4%,17.4%were diagnosed with non-cardiac chest pain,3.5%treated as stable angina,8.2%reviewed by cardiologists,electronic medical records were not available in 10.4%.Receiver operating characteristic curves for CAD used uscTnI values measured in patients who underwent functional testing,angiogram or CCTA.Values>0.52 ng/L showed 100%sensitivity and at>11.6 ng/L showed 100%specificity.In the range>0.52-11.6 ng/L,uscTnI may not have the same diagnostic potential.In patients assigned to coronary angiogram higher concentrations of uscTnI was associated with severe CAD.Low levels of uscTnI and low pre-test probability of CAD(QRISK3)may decrease patient numbers assigned to CCTA.CONCLUSION The uscTnI diagnostic cut-off values in a RACPC will depend on patient population and their presenting co-morbidity.In the presence of clinical comorbidities and previous CAD the uscTnI needs to be used in conjunction with clinical assessment.

New approach to the automatic segmentation of coronary artery in X-ray angiograms

For the segmentation of X-ray angiograms （XRA）, the essential feature and the prior knowledge of angiographic image were analyzed, and a multi-feature based fuzzy recognition （MFFR） algorithm was proposed to infer the local vessel structure in this paper. Guided by the prior knowledge of artery vessel, a probability tracking operator （PTO） can rapidly track along the artery tree, and walk across the weak region or gaps because of disturbance or preprocessing to angiographic image. Another, the accurate measurement of the vascular axis-lines and diameters can be synchronously implemented in the tracking process. To correctly evaluate the proposed method, a simulated image of CAT and some clinical XRA images were used in the experimentations. The algorithms performed better than the conventional one： given one start-point, on average 92.7% of the visible segments or branches was automatically delineated; the correctness ratio of vessel structure inference reached to 90.0% on the average.

An analysis of factors in fluencing electrocardiogram stress test for detecting coronary heart disease

Objective To evaluate factors influencing electrocardiogram (ECG) stres s test Methods The treadmill stress test and coronary angiogram (CAG) records were reviewed retrospectively in 435 consecutive patients with chest pain betwee n 1991 and 1997 There were 44 cases with normal CAG but positive exercise stre s s test results (falsepositive, Group A), and 33 cases with both negative CAG a nd negative exercise test (truenegative, Group B) The baseline ECG, echocard i ogram, abnormal systolic blood pressure response and history of diabetes mellit us and hypertension in the two groups were compared Results There was no significant difference between the two groups with r espect to age, gender, and antianginal medication More patients in Group A had hype rtension (523% vs 273%, P <005) and diabetes mellitus (15 9% v s 0%, P <005) Left ventricular (LV) hypertrophy in baseline E C G and by echocardiogram was more often present in Group A (250% vs 30%, P <005; 364% vs 121%, P <005) There were no signi fican t differences between the two groups with respect to maximal heart rate, maxima l s ystolic blood pressure (BP), metabolic equivalents, postexercise systolic BP, te rmination for exercise test, baseline ECG with bundle branch block and ST depres sion Conclusion Our results suggest that LV hypertrophy and a history of hyp ertension or diabetes mellitus are the main factors influencing ECG stress test for detecting coronary heart disease