Prognostic value of computed tomographic coronary angiography and exercise electrocardiography for cardiovascular events

BACKGROUND/AIMS: This study is a head-to-head comparison of predictive values for long-term cardiovascular outcomes between exercise electrocardiography (ex-ECG) and computed tomography coronary angiography (CTCA) in patients with chest pain. METHODS: Four hundred and forty-two patients (mean age, 56.1 years; men, 61.3%) who underwent both ex-ECG and CTCA for evaluation of chest pain were included. For ex-ECG parameters, the patients were classified according to negative or positive results, and Duke treadmill score (DTS). Coronary artery calcium score (CACS), presence of plaque, and coronary artery stenosis were evaluated as CTCA parameters. Cardiovascular events for prognostic evaluation were defined as unstable angina, acute myocardial infarction, revascularization, heart failure, and cardiac death. RESULTS: The mean follow-up duration was 2.8 ± 1.1 years. Fifteen patients experienced cardiovascular events. Based on pretest probability, the low- and intermediate-risks of coronary artery disease were 94.6%. Odds ratio of CACS > 40, presence of plaque, coronary stenosis ≥ 50% and DTS ≤ 4 were significant (3.79, p = 0.012; 9.54, p = 0.030; 6.99, p < 0.001; and 4.58, p = 0.008, respectively). In the Cox regression model, coronary stenosis ≥ 50% (hazard ratio, 7.426; 95% confidence interval, 2.685 to 20.525) was only significant. After adding DTS ≤ 4 to coronary stenosis ≥ 50%, the integrated discrimination improvement and net reclassification improvement analyses did not show significant. CONCLUSIONS: CTCA was better than ex-ECG in terms of predicting long-term outcomes in low- to intermediate-risk populations. The predictive value of the combination of CTCA and ex-ECG was not superior to that of CTCA alone.

Differential Prognostic Value of Coronary Computed Tomography Angiography in Relation to Exercise Electrocardiography in Asymptomatic Subjects

BACKGROUND: To explore the prognostic performance of coronary computed tomography angiography (CCTA) and exercise electrocardiography (XECG) in asymptomatic subjects. METHODS: We retrospectively enrolled 812 (59 +/- 9 years, 60.8% male) asymptomatic subjects who underwent CCTA and XECG concurrently from 2003 through 2009. Subjects were followed-up for major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, unstable angina, and revascularization after 90 days from index CCTA. RESULTS: The prevalence of occult coronary artery disease (CAD) detected by CCTA was 17.5% and 120 subjects (14.8%) had positive XECG. During a mean follow-up of 37 +/- 16 months, nine subjects experienced MACE. In multivariable Cox-regression analysis, only the presence of CAD by CCTA independently predicted future MACE (p = 0.002). Moreover, CAD by CCTA improved the predictive value when added to a clinical risk factor model using the likelihood ratio test (p < 0.001). Notably, the prognostic value of CCTA persisted in the moderate-to-high-risk group as classified by the Duke treadmill score (p = 0.040), but not in the low-risk group (p = 0.991). CONCLUSION: CCTA provides incremental prognostic benefit over and above XECG in an asymptomatic population, especially for those in a moderate-to-high-risk group as classified by the Duke treadmill score. Risk stratification using XECG may prove valuable for identifying asymptomatic subjects who can benefit from CCTA.

Myocardial FFR (Fractional Flow Reserve) in patients with angiographically intermediate coronary artery stenosis - an initial institutional experience.

RESEARCH ARTICLE January-March 2013 | Volume 1 | Issue 1 | Page: 4-11 Myocardial FFR (Fractional Flow Reserve) in patients with angiographically intermediate coronary artery stenosis - an initial institutional experience Jagadish H. Ramaiah*, Raghu T. Ramegowda, Srinivas B. Chikkaswamy, Manjunath C. Nanjappa Sri Jayadeva Institute of Cardiovascular Sciences & Research, Jaya Nagar 9th Block, BG Road, Bangalore - 560069, Karnataka, INDIA Correspondence to: Dr. Jagadish H. Ramaiah, Email: jagadishhr@rediffmail.com Background: The clinical significance of coronary artery stenosis of intermediate severity can be difficult to determine. The management of intermediate coronary lesions, defined by a diameter stenosis of ≥40% to ≤70%, continues to be a therapeutic dilemma for cardiologists. The 2-dimensional representation of the arterial lesion provided by angiography is limited in distinguishing intermediate lesions that require stenting from those that simply need appropriate medical therapy. In the era of drug-eluting stents, some might propose that stenting all intermediate coronary lesions is an appropriate solution. However, the possibility of procedural complications such as coronary dissection, no reflow phenomenon, in-stent restenosis, and stent thrombosis requires accurate stratification of patients with intermediate coronary lesions to appropriate therapy. Myocardial fractional flow reserve (FFR) is an index of the functional severity of coronary stenosis that is calculated from pressure measurements made during coronary angiography. The objective of the study is to evaluate the usefulness of FFR in patients with angiographically intermediate coronary artery stenosis. Methods: 20 patients with intermediate coronary stenosis and chest pain of uncertain origin. The Exercise Electrocardiography (TMT), Myocardial Perfusion Imaging study (MPI), Quantitative Coronary Angiography (QCA) were compared with the results of FFR measurements. Results: 20 patients were undergone FFR measurement during the study period. With the mean age of 57.25±11.2 and male patients were 16 (80%), female patients 4 (20%), in all 13 patients with an FFR of <0.75, reversible myocardial ischemia was demonstrated unequivocally on at least one noninvasive test. In contrast, 5 of 7 patients with an FFR of >0.75 tested negative for reversible myocardial ischemia on TMT and MPI study. No revascularization procedures were performed in 7 (35%) patients, and no adverse cardiovascular events were noted in all these patients during 6 months of follow-up. Conclusions: In patients with coronary stenosis of intermediate severity, FFR appears to be a useful index of the functional severity of the stenosis and the need for coronary revascularization

Effect of depside salt from salvia miltiorrhiza on angina pectoris and platelet function / 介入放射学杂志

Objective To study the effect of Depside Salt from Salvia Miltiorrhiza on angina pectoris and platelet function.Methods The study group was comprised of 56 patients with stable angina,who were randomly divided into the high-dosage Depside Salt from Salvia Miltiorrhiza group,the low-dosage Depside Salt from Salvia Miltiorrhiza group and the Danshen control group. Before and after the 14-day treatment,the clinical symptom and serum level of PAG, P-selectin were measured,and exercise electrocardiography was performed. Results After treatment with Depside Salt from Salvia Miltiorrhiza,the symptom of angina pectoris was alleviated and exercise ECG was improved,while no significant difference was found compared with control group.Serum PAG and P-selectin were decreased after treatment with Depside Salt from Salvia Miltiorrhiza ,and significantly more than Danshen.Conclusion Depside Salt from Salvia Miltiorrhiza injection can remarkably inhibite the aggregation and activation of platelet,and is effective for angina pectoris.

The Usefulness of Supine Bycycle Stress Echocardiography for Evaluationg Coronary Artery Disease: Comparision with Exercise Electrocardiography

BACKGROUND AND OBJECTIVES: Posttreadmill exercise echocardiography or supine bicycle exercise echocardiography are widely used for evaluating coronary artery disease. In comparison with posttreadmill exercise echocardiography, supine bicycle stress echocardiography (SBSE) has the advantage of imaging during stress and at peak exercise and ischemic wall motion abnormalities at the time of imaging are more frequent and more extensive. Therefore, SBSE is a valuable tool for evaluation of coronary artery disease. This study was designed to provide the hemodynamic changes during exercise and compare the sensitivity, specificity and predictive values of the wall motion abnormalities of supine bicycle stress echocardiography during peak exercise with those of 12-lead electrocardiography (ECG) during exercise for evaluating coronary artery disease. MATERIALS AND METHODS: One hundred patients for evaluation of possible coronary artery disease performed supine bicycle stress echocardiography. This study consisted of 51 patients who underwent coronary arteriography. Significant coronary artery disease was defined as the presence of 50% or 75% diameter reduction determined by magnified electronic caliper measurements, compairing the accuracy of supine bicycle stress echocardiography to that of 12-lead exercise ECG. RESULTS: 1) Fifty-one patients (31 men, 20 women) underwent both supine bicycle stress echocardiography and coronary arteriography, the results were age (54.5+/-9.8 years), heart rates(68+/-12 vs 12422 beats/min), systolic blood pressure (130+/-23 vs 175+/-32 mmHg), diastolic blood pressure (76+/-13 vs 96+/-25mmHg) in resting vs during peak exercise and % predicted maximal heart rate (72+/-10%). 2) At coronary artery disease was defined as the presence of 50% diameter reduction, 26 of 51 patients were included(19 with single-vessel, 6 with double-vessel and 1 with triple-vessel disease). SBSE was 69.2% sensitivity, 64% specificity, 66.7% positive predictive value and 66.7% negative predictive value compared with 33.3% sensitivity, 70.8% specificity of ECG during exercise. 3) At coronary artery disease was defined as the presence of 75% diameter reduction, 19 of 51 patients were included(16 with single-vessel and 3 with double-vessel disease). SBSE was 84.2% sensitivity, 65.6% specificity, 59.3% positive predictive value and 45.8% negative predictive value compared with 31.6% sensitivity, 68.7% specificity of 12-lead ECG during exercise. 4) There were no serious complications like that ventricular tachycardia or fibrillation, severe hypotension or hypertension, acute myocardial infarction and death during exercise test. CONCLUSIONS: The sensitivity of supine bicycle stress echocardiography during peak exercise was higher than 12-lead ECG during exercise for evaluation of coronary artery disease because wall motion abnormality of echocardiography was more early detected than ECG changes during exercise at same amounts of workload. Therefore, supine bicycle stress echocardiography is a useful tool for evaluating coronary artery disease.

Localization of Ischemic Area with Exercise Electrocardiography in Angina Pectoris: Correlation with 99mTc-MIBI Myocardial Perfusion Scanning

BACKGROUND: The purpose of the study was to determine the value of exercise electrocardiography in predicting the area of myocardial ischemia. METHOD: Seventy-six anginal patients with a perfusion defect in one vessel territory on exercise 99mTc-MIBI myocardial perfusion scan were studied. Each patient underwent exercise electrocardiograhy using modified Bruce protocol. Exercise electrocardiography was interpreted as abnormal when the horizontal or downsloping depression in ST segment was 0.1 mV or greater at 80 msec after the J point during exercise. Forty-eight patients had exercise induced ST-segment depression. RESULT: Twenty-five patients had exercise induced ST-segment depression in single lead-group and 23 patients had in multiple lead-groups. In 18 patients (18/23) with exercise induced ST-segment depression in multiple lead-groups, the perfusion defect involved the apical area on myocardial perfusion scanning and in 21 patients (21/25) with ST-segment depression in single lead-group, the perfusion defect did not involve the apical area. In patients without perfusion defect in the apical area, ST-segment depression in anterior lead-group (V1 to V4) was associated with myocadial perfusion defects in left anterior descending artery territories in five of five cases (100%), ST-segment depression in lateral lead-group (I, aVL, V5, V6) was associated with defects in left circumflex artery territories in six of six cases (100%), and ST-segment depression in inferior lead group (II, III, aVF) was associated with defects in right coronary artery territories in nine of ten (90%) (p<0.01). In patients with perfusion defect in the apical area, exercise induced ST-segment depressions were observed in multiple lead-groups (18/22). CONCLUSION: ST-segment depression on 12 lead exercise electrocardiography was a good predictor of the site of myocadial ischemia in anginal patients with single vessel territory ischemia when ST-segment depression developed in single lead group. However, ST-segment depressions in mutiple lead-groups suggested that the perfusion defect involved the apical area and did not predict the site of myocardial ischemia.