Lipoprotein(a) levels are associated with aortic valve calcification in asymptomatic patients with familial hypercholesterolaemia.

OBJECTIVES: Lipoprotein(a) [Lp(a)] is an independent risk factor for aortic valve stenosis and aortic valve calcification (AVC) in the general population. In this study, we determined the association between AVC and both plasma Lp(a) levels and apolipoprotein(a) [apo(a)] kringle IV repeat polymorphisms in asymptomatic statin-treated patients with heterozygous familial hypercholesterolaemia (FH). METHODS: A total of 129 asymptomatic heterozygous FH patients (age 40-69 years) were included in this study. AVC was detected using computed tomography scanning. Lp(a) concentration and apo(a) kringle IV repeat number were measured using immunoturbidimetry and immunoblotting, respectively. Univariate and multivariate logistic regression were used to assess the association between Lp(a) concentration and the presence of AVC. RESULTS: Aortic valve calcification was present in 38.2% of patients, including three with extensive AVC (>400 Agatston units). Lp(a) concentration was significantly correlated with gender, number of apo(a) kringle IV repeats and the presence and severity of AVC, but not with coronary artery calcification (CAC). AVC was significantly associated with plasma Lp(a) level, age, body mass index, blood pressure, duration of statin use, cholesterol-year score and CAC score. After adjustment for all significant covariables, plasma Lp(a) concentration remained a significant predictor of AVC, with an odds ratio per 10-mg dL(-1) increase in Lp(a) concentration of 1.11 (95% confidence interval 1.01-1.20, P = 0.03). CONCLUSION: In asymptomatic statin-treated FH patients, plasma Lp(a) concentration is an independent risk indicator for AVC.

First-line evaluation of coronary artery disease with coronary calcium scanning or exercise electrocardiography.

BACKGROUND: Although conventional (CAG) and computed tomography angiography (CTA) are reliable diagnostic modalities for exclusion of obstructive coronary artery disease (CAD), they are costly and with considerable exposure to radiation and contrast media. We compared the accuracy of coronary calcium scanning (CCS) and exercise electrocardiography (X-ECG) as less expensive and non-invasive means to rule out obstructive CAD. METHODS: In a rapid-access chest pain clinic, 791 consecutive patients with stable chest pain were planned to undergo X-ECG and dual-source CTA with CCS. According to the Duke pre-test probability of CAD patients were classified as low (<30%), intermediate (30-70%) or high risk (>70%). Angiographic obstructive CAD (>50% stenosis by CAG or CTA) was found in 210/791 (27%) patients, CAG overruling any CTA results. RESULTS: Obstructive CAD was found in 12/281 (4%) patients with no coronary calcium and in 73/319 (23%) with a normal X-ECG (p<0.001). No coronary calcium was associated with a substantially lower likelihood ratio compared to X-ECG; 0.11, 0.13 and 0.13 vs. 0.93, 0.55 and 0.46 in the low, intermediate and high risk group. In low risk patients a negative calcium score reduced the likelihood of obstructive CAD to less than 5%, removing the need for further diagnostic work-up. CCS could be performed in 754/756 (100%) patients, while X-ECG was diagnostic in 448/756 (59%) patients (p<0.001). CONCLUSIONS: In real-world patients with stable chest pain CCS is a reliable initial test to rule out obstructive CAD and can be performed in virtually all patients.

Diagnostic performance of exercise bicycle testing and single-photon emission computed tomography: comparison with 64-slice computed tomography coronary angiography.

To conduct a comparison of the diagnostic performance of exercise bicycle testing and single-photon emission computed tomography (SPECT) with computed tomography coronary angiography (CTCA) for the detection of obstructive coronary artery disease (CAD) in patients with stable angina. 376 symptomatic patients (254 men, 122 women, mean age 60.4 ± 10.0 years) referred for noninvasive stress testing (exercise bicycle test and/or SPECT) and invasive coronary angiography were included. All patients underwent additional 64-slice CTCA. The diagnostic performance of exercise bicycle testing (ST segment depression), SPECT (reversible perfusion defect) and CTCA (≥50% lumen diameter reduction) was presented as sensitivity, specificity, positive and negative predictive value (PPV and NPV) to detect or rule out obstructive CAD with quantitative coronary angiography as reference standard. Comparisons of exercise bicycle testing versus CTCA (n = 334), and SPECT versus CTCA (n = 61) were performed. The diagnostic performance of exercise bicycle testing was significantly (P value < 0.001) lower compared to CTCA: sensitivity of 76% (95% CI, 71-82) vs. 100% (95% CI, 97-100); specificity of 47% (95% CI, 36-58) vs. 74% (95% CI, 63-82). We observed a PPV of 70% (95% CI, 65-75) vs. 91% (95% CI, 87-94); and NPV of 30% (95%, 25-35) vs. 99% (95%, 90-100). There was a statistically significant difference in sensitivity (P value < 0.05) between SPECT and CTCA: 89% (95% CI, 75-96) vs. 98% (95% CI, 87-100); but not in specificity (P value > 0.05): 77% (95% CI, 50-92) vs. 82% (95% CI, 56-95). We observed a PPV of 91% (95% CI, 77-97) vs. 93% (95% CI, 81-98); and NPV of 72% (95%, 46-89) vs. 93% (95%, 66-100). SPECT and CTCA yielded higher diagnostic performance compared to traditional exercise bicycle testing for the detection and rule out of obstructive CAD in patients with stable angina.

Coronary plaque burden in patients with stable and unstable coronary artery disease using multislice CT coronary angiography.

PURPOSE: We evaluated the multislice computed tomography (MSCT) coronary plaque burden in patients with stable and unstable angina pectoris. MATERIALS AND METHODS: Twenty-one patients with stable and 20 with unstable angina pectoris scheduled for conventional coronary angiography (CCA) underwent MSCT-CA using a 64-slice scanner offering a fast rotation time (330 ms) and higher X-ray tube output (900 mAs). To determine the MSCT coronary plaque burden, we assessed the extent (number of diseased segments), size (small or large), type (calcific, noncalcific, mixed) of plaque, its anatomic distribution and angiographic appearance in all available ≥2-mm segments. In a subset of 15 (seven stable, eight unstable) patients, the detection and classification of coronary plaques by MSCT was verified by intracoronary ultrasound (ICUS). RESULTS: Sensitivity and specificity of MSCT compared with ICUS to detect significant plaques (defined as ≥1-mm plaque thickness on ICUS) was 83% and 87%. Overall, 473 segments were examined, resulting in 11.6±1.5 segments per patient. Plaques were present in 62% of segments and classified as large in 47% of diseased segments. Thirty-two percent were noncalcific, 25% calcific and 43% mixed. Plaques were most frequently located in the proximal and mid segments. Plaque was found in 33% of segments classified as normal on CCA. Unstable patients had significantly more noncalcific plaques when compared with stable patients (45% vs. 21%, p<0.05). CONCLUSIONS: MSCT-CA provides important information regarding the coronary plaque burden in patients with stable and unstable angina.

The role of multi-slice computed tomography in stable angina management: a current perspective.

Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD. However, because CTCA is moderately predictive for indicating the functional significance of a lesion, the combination of anatomic and functional imaging will become increasingly important. The technology will continue to improve with better spatial and temporal resolution at low radiation exposure, and CTCA may eventually replace invasive coronary angiography. The establishment of the precise role of CTCA in the diagnosis and management of patients with stable angina requires high-quality randomised study designs with clinical outcomes as a primary outcome.

Cardiac magnetic resonance imaging in stable ischaemic heart disease.

Cardiac magnetic resonance imaging (CMR) is a new robust versatile non-invasive imaging technique that can detect global and regional myocardial dysfunction, presence of myocardial ischaemia and myocardial scar tissue in one imaging session without radiation, with superb spatial and temporal resolution, inherited three-dimensional data collection and with relatively safe contrast material. The reproducibility of CMR is high which makes it possible to use this technique for serial assessment to evaluate the effect of revascularisation therapy in patients with ischaemic heart disease.

Prognostic value of CT coronary angiography: focus on obstructive vs. nonobstructive disease and on the presence of left main disease.

PURPOSE: The authors investigated the prognostic value of computed tomography coronary angiography (CTCA) for major adverse cardiac events (MACE) in patients with suspected or known coronary artery disease (CAD), with particular focus on left main (LM) disease and obstructive vs. nonobstructive disease. MATERIALS AND METHODS: A total of 727 consecutive patients (485 men, age 62 ± 11 years) with suspected (514; 70.1%) or known (213; 29.9%) CAD underwent CTCA. Patients were followed up for the occurrence of MACE (i.e. cardiac death, nonfatal myocardial infarction, unstable angina, percutaneous/surgical revascularisation). RESULTS: A total of 117 MACE [five cardiac deaths, 11 acute myocardial infarctions (AMI), five unstable angina, 86 percutaneous coronary interventions, ten coronary artery bypass grafts] occurred during a mean follow-up of 20 months. Severity and extension of CAD was associated with a progressively worse prognosis. The event rate was 0% among patients with normal coronary arteries at CTCA. The presence of LM disease was not associated with a worse prognosis either in patients with no history of CAD or in those with a history of CAD. At multivariate analysis, presence of obstructive CAD and diabetes were the only independent predictors of MACE. CONCLUSIONS: Evaluation of atherosclerotic burden by CTCA provides an independent prognostic value for prediction of MACE. Patients with normal CTCA findings have an excellent prognosis at follow-up.

Ultrasonographic and DSCT scan analysis of single lima versus arterial T grafts 12 years after surgery.

AIM: The aim of this study was to investigate long-term graft outcome in patients with left internal mammary artery to left anterior descending coronary artery (LIMA-LAD) and T-grafts by ultrasonography and dual source computed tomography (DSCT) and to analyse if ultrasonography can determine graft patency. METHODS: Thirty-two patients, 28 males, 50.8+/-8.8 years at operation, were studied. Fifteen patients with single LIMA-LAD and additional vein grafts (group I) and 17 patients with LIMA-free right internal mammary artery (FRIMA) T-grafts (group II) underwent DSCT, transthoracic ultrasonography of the LIMA and an electrocardiogram. Differences were tested with unpaired and paired t tests. RESULTS: In group I, 4.1+/-1.1 and in group II, 4.5+/-1.1 anastomoses/patients were performed. DSCT showed three string sign LIMA (20%) grafts and six occluded venous anastomoses (13%) in group I and three (distal) string sign LIMA grafts (18%), seven occluded LIMA anastomoses (23%) and nine occluded FRIMA anastomoses (23%) in group II. Ultrasonographic variables in the proximal part of the LIMA graft did not differ between the groups. No effect was found for proximal string sign LIMA grafts in ultrasonographic graft performance. CONCLUSION: Ultrasonography cannot distinguish between string sign and patent single LIMA or T-grafts nor demonstrate distal anastomosis patency in T-grafts 12 years after surgery.

Impact of tube current in the quantitative assessment of acute reperfused myocardial infarction with 64-slice delayed-enhancement CT: a porcine model.

PURPOSE: This study evaluated the impact of tube current (mAs) in delayed-enhancement computed tomography (CT) imaging for assessing acute reperfused myocardial infarction in a porcine model. MATERIALS AND METHODS: In five domestic pigs (mean weight 24 kg), the circumflex coronary artery was balloon-occluded for 2 h and then reperfused. After 5 days, CT imaging was performed following administration of iodinated contrast material. A 64-slice CT system was used to perform first-pass coronary angiography with a tube current of 15 mAs/kg [Arterial Phase (ART)] followed by two delayed-enhancement (DE) scans 15 min after contrast material administration, with a tube current of 15 mAs/kg and 37.5 mAs/kg, respectively (DE(1) and DE(2)). The mean heart rate decreased to 51±9 beats/min after administration of zatebradine (10 mg/kg IV). The data set was reconstructed during the end-diastolic phase of the cardiac cycle. Areas with DE, no reflow and remote myocardium [remote left ventricular (LV)] were calculated. CT values expressed in Hounsfield units (HU) were measured using five regions of interest (ROI): DE, no reflow, remote LV, LV cavity (LV lumen) and in air, respectively. Differences, correlations, image quality [signal-to-noise ratio (SNR)] and contrast resolution [contrast-to-noise ratio (CNR)] were calculated. RESULTS: Significant differences were found between attenuation of areas of DE, no reflow and remote LV (p<0.001) within the different scans. There was a fair correlation between DE and no-reflow attenuation (r=0.6; p<0.001). In DE(1) vs. DE(2), areas of DE and no reflow were not significantly different (p>0.05). The SNR and CNR were not significantly different in DE(1) vs. DE(2) (p>0.05). CONCLUSIONS: Tube current does not significantly affect infarction area, image quality or contrast resolution of DE imaging with CT.

Impact of contrast material volume on quantitative assessment of reperfused acute myocardial infarction using delayed-enhancement 64-slice CT: experience in a porcine model.

PURPOSE: Our purpose in this study was to compare the impact of contrast material volume in delayed-enhancement computer tomography (CT) imaging for assessing acute reperfused myocardial infarction. MATERIALS AND METHODS: In five domestic pigs (20-30 kg), the circumflex coronary artery (CX) was balloon-occluded for 2 h followed by reperfusion. After 5 days, CT imaging was performed after intravenous administration of iodinated contrast material (Iomeprol 400 mgI/ml; Bracco, Italy). A 64-slice multidetector CT (MDCT) (Sensation 64, Siemens) scanner was used for imaging, with standard angiography characteristics. Three scans were performed: first, coronary angiography at first pass with 1.25 gI/kg of contrast material (ART); and remaining delayed-enhancement (DE(1)-DE(2)) 15 min after administration of 1.25 (DE(1)) and 15 min after additional administration of 2.50 gI/kg (=total 3.75 gI/kg - DE(2)). Mean heart rate decreased to 51+/-9 bpm after intravenous administration of Zatebradine (10 mg/kg). Data sets were reconstructed during the end-diastolic phase of the cardiac cycle. Areas of infarction-enhanced (DE), no-reflow (no-reflow) and remote myocardial [remote left ventricle (LV)] were manually contoured. CT attenuation values (Hounsfield units) were measured using five regions of interest: DE, no-reflow, remote LV, left ventricular cavity (lumen LV) and in air. Differences, correlations, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. RESULTS: We found significant differences between the attenuation of DE, no-reflow and remote LV (p<0.001). DE and no-reflow size were assessed accurately with DEMDCT. In particular, SNR and CNR showed higher values in DE(2) (approximately 6.0 and 3.5, respectively; r(2)=0.90) vs. DE(1) (approximately 4.0 and 2.2, respectively; r(2)=0.85). CONCLUSIONS: The increase of contrast material volume determines a significant improvement in myocardial infarction image quality with DE-MDCT.

Combining noninvasive anatomical imaging with invasive functional information: an unconventional but appropriate hybrid approach.

CT coronary angiography (CTCA) allows accurate noninvasive imaging of the coronary arteries. As illustrated by this case report, the threedimensional information provided by this technique might be of value to resolve complex coronary pathology encountered in the cathlab. However, the limitations inherent to an anatomical test also apply for CTCA, and bring in the need for functional information to ensure adequate patient management. (Neth Heart J 2009;17:292-4.).

Coronary artery anomalies detected by MSCT-coronary angiography in the adult.

BACKGROUND: Before coronary evaluation by modern imaging techniques was feasible, premorbid diagnoses of coronary artery anomalies (CAAs) were usually made fortuitously by invasive coronary angiography (ICA). However, this technique is limited by its invasive and projectional nature. Coronary magnetic resonance angiography (CMRA) and multi-slice computed tomography (MSCT) broadened clinical information by enabling visualisation of the coronary arteries in their anatomical environment. METHODS: This case series visualises and reviews anomalous coronary artery from the opposite sinus (ACAOS) and coronary artery fistulae. All CAAs were detected by means of 64-slice dual source computed tomography after 1000 cardiac scans at the Erasmus MC, Rotterdam, the Netherlands. RESULTS: Eight ACAOS cases, one anomalous left coronary artery from the pulmonary artery (ALCAPA) and one congenital aneurysm of an aortic sinus were found. Seven out often detected CAAs were considered malignant whereas three CAAs of the ACAOS type (retroaortic path) were considered benign. Significant coronary artery disease was found in three out of eight ACAOS cases. In one of the ACAOS cases complete evaluation of the anomalous coronary artery was limited by motion artifacts. All five cases of right ACAOS were referred for MSCT because the right coronary artery could not be located by invasive angiography. CONCLUSION: All CAAs were easy to diagnose because of 3D imaging and high temporal and spatial resolution. High resolution made it possible to not only depict coronary artery abnormalities, but also to quantify luminal and vessel properties such as stenosis grade, aspects of plaque, anomalous vessel length, luminal area ratio and the asymmetry ratio. Because of its comprehensiveness, MSCT can be an effective imaging modality in patients suspected of coronary artery abnormalities caused by coronary artery disease, CAAs, or a combination of both. (Neth Heart J 2008;16:369-75.).

Dual source coronary computed tomography angiography for detecting in-stent restenosis.

OBJECTIVE: To evaluate the performance of dual source CT coronary angiography (DSCT-CA) in the detection of in-stent restenosis (>or=50% luminal narrowing) in symptomatic patients referred for conventional angiography (CA). DESIGN/ PATIENTS: 100 patients (78 males, age 62 (SD 10)) with chest pain were prospectively evaluated after coronary stenting. DSCT-CA was performed before CA. SETTING: Many patients undergo coronary artery stenting; availability of a non-invasive modality to detect in-stent restenosis would be desirable. RESULTS: Average heart rate (HR) was 67 (SD 12) (range 46-106) bpm. There were 178 stented lesions. The interval between stenting and inclusion in the study was 35 (SD 41) (range 3-140) months. 39/100 (39%) patients had angiographically proven restenosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DSCT-CA, calculated in all stents, were 94%, 92%, 77% and 98%, respectively. Diagnostic performance at HR <70 bpm (n = 69; mean 58 bpm) was similar to that at HR >or=70 bpm (n = 31; mean 78 bpm); diagnostic performance in single stents (n = 95) was similar to that in overlapping stents and bifurcations (n = 83). In stents >or=3.5 mm (n = 78), sensitivity, specificity, PPV, NPV were 100%; in 3 mm stents (n = 59), sensitivity and NPV were 100%, specificity 97%, PPV 91%; in stents or=3.5 mm was significantly higher than in stents

Multislice computed tomography coronary angiography: clinical applications.

Cardiac and coronary computed tomography (CT) is becoming increasingly common in clinical practice. Even if there is no well-established evidence, this diagnostic modality is so strong and effective and, in skilled hand, it can be readily used in clinical practice. After learning its potential and the technical limits, this tool could be used for risk stratification as well as for revascularization evaluation. In this review, we will describe the results of present literature, clinical applications at present considered suitable to CT technology (i.e. 64-slice and dual-source scanners) and future applications and innovations.

Spiral multislice computed tomography coronary angiography: a current status report.

Multislice computed tomography coronary angiography (MSCT-CA) has emerged as a powerful noninvasive diagnostic modality to visualize the coronary arteries and to detect significant coronary stenoses. The latest generation 64-slice computed tomography (CT) scanners is a robust technique which allows high-resolution, isotropic, nearly motion-free coronary imaging. Coronary stenoses are detected with high sensitivity and a normal scan accurately rules out the presence of a coronary stenosis. With the introduction of further novel concepts in CT-technology one may expect that MSCT-CA will become a clinically used diagnostic tool.

[Background and application of multi-slice CT in the diagnosis of coronary artery disease]. / Achtergrond en toepassing van 'multi-slice'-CT in de diagnostiek van coronairlijden.

Multi-slice CT coronary angiography is a rapidly developing noninvasive diagnostic technique that can be used to detect coronary stenosis. Detection of coronary stenosis by coronary angiography is usually hindered by limited image quality, motion artefacts caused by heart contractions, and artefacts caused by extensive calcification. In addition, the radiation exposure is relatively great. Multi-slice CT coronary angiography, however, can reliably rule out coronary stenosis. At this time, multi-slice CT coronary angiography is not a routine part of the diagnosis of coronary artery disease. In the future, the target population for this technique may include asymptomatic high-risk patients and symptomatic low- or intermediate-risk patients for severe coronary artery disease.