Management of Asymptomatic Patients With Positive Coronary Artery Calcium Scans.

BACKGROUND: The widespread availability of the coronary artery calcium scan to diagnose coronary artery atheroma semiquantitatively and its prognostic significance has frequently resulted in a difficult therapeutic decision for physicians caring for asymptomatic patients. PATIENTS AND RISK FACTORS: Of particular concern are patients over 40 years of age and young adults characterized by multiple cardiovascular risk factors. The correct prognostic interpretation of coronary artery calcium scores and the potential benefits and risks of various therapeutic modalities need to be understood. CONCLUSION: This review describes the therapeutic choices available to endocrinologists and provides recommendations for various treatment options.

Outcomes of anatomical versus functional testing for coronary artery disease.

BACKGROUND: Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care. METHODS: We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure. RESULTS: The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P=0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001). CONCLUSIONS: In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.).

Venous thromboembolism: annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates.

Healthcare reform is upon the United States (US) healthcare system. Prioritisation of preventative efforts will guide necessary transitions within the US healthcare system. While annual deep-vein thrombosis (DVT) costs have recently been defined at the US national level, annual pulmonary embolism (PE) and venous thromboembolism (VTE) costs have not yet been defined. A decision tree and cost model were developed to estimate US health care costs for total PE, total hospital-acquired PE, and total hospital-acquired "preventable" PE. The previously published DVT cost model was modified, updated and combined with the PE cost model to elucidate the same three categories of costs for VTE. Direct and indirect costs were also delineated. For VTE in the base model, annual cost ranges in 2011 US dollars for total, hospital- acquired, and hospital-acquired "preventable" costs and were $13.5-$27.2, $9.0-$18.2, and $4.5-$14.2 billion, respectively. The first sensitivity analysis, with higher incidence rates and costs, demonstrated annual US total, hospital-acquired, and hospital-acquired "preventable" VTE costs ranging from $32.1-$69.3, $23.7-$51.5, and $11.9-$39.3 billion, respectively. The second sensitivity analysis with long-term attack rates (LTAR) for recurrent events and post-thrombotic syndrome and chronic pulmonary thromboembolic hypertension demonstrated annual US total, hospital-acquired, and hospital-acquired "preventable" VTE costs ranging from $15.4-$34.4, $10.3-$25.4, and $5.1-$19.1 billion, respectively. PE costs comprised a majority of the VTE costs. Prioritisation of effective VTE preventative strategies will reduce significant costs, morbidity and mortality within the US healthcare system. The cost models may be utilised to estimate other countries' costs or VTE-specific disease states.

Quantitative assessment of in-stent dimensions: a comparison of 64 and 16 detector multislice computed tomography to intravascular ultrasound.

OBJECTIVES: To determine the utility of multislice computed tomography (MSCT) technology to evaluate coronary stent luminal diameter. BACKGROUND: Stent metal induced "blooming" artifact makes quantitative coronary angiography by MSCT difficult. There is a paucity of data on the efficacy of using 64 and 16 detector MSCT in evaluating coronary stents. METHODS: We evaluated four commercially available bare metal and polymer coated drug eluting stents using 64 and 16 detector MSCT for the following: (1) Strut density in Hounsfield's Units (Hu) using a 2 mm MIP; (2) In-stent luminal diameter (ISLD) measured by MSCT compared to intravascular ultrasound (IVUS). RESULTS: Increased strut thickness did not correlate with greater strut density as measured in Hu (R(2) = 0.05, P = 0.29). The ISLD by 16 MSCT vs. IVUS is: Vision 1.63 +/- 0.58 mm vs. 2.8 +/- 0.0; Cypher 1.80 +/- 0.00 vs. 2.9 +/- 0.0; Taxus 1.87 +/- 0.58 vs. 2.9 +/- 0.0; Liberté 1.80 +/- 0.10 vs. 3.0 +/- 0.1 (P < 0.01). ISLD determined by 64 MSCT vs. IVUS is: Vision 1.73 +/- 0.06 mm vs. 2.8 +/- 0.0; Cypher 1.87 +/- 0.12 vs. 2.9 +/- 0.0; Taxus 1.77 +/- 0.06 vs. 2.9 +/- 0.0; Liberté 1.80 +/- 0.10 vs. 3.0 +/- 0.1 (P < 0.01). CONCLUSIONS: When compared to IVUS measurements, MSCT results in a significant, underestimation of ISLD. This consistent underestimation (even with 64 MSCT) limits the applicability of CT angiography to quantify in-stent restenosis.