Prognostic assessment of stable coronary artery disease as determined by coronary computed tomography angiography: a Danish multicentre cohort study.

Aims: To examine the 3.5 year prognosis of stable coronary artery disease (CAD) as assessed by coronary computed tomography angiography (CCTA) in real-world clinical practice, overall and within subgroups of patients according to age, sex, and comorbidity. Methods and results: This cohort study included 16,949 patients (median age 57 years; 57% women) with new-onset symptoms suggestive of CAD, who underwent CCTA between January 2008 and December 2012. The endpoint was a composite of late coronary revascularization procedure >90 days after CCTA, myocardial infarction, and all-cause death. The Kaplan-Meier estimator was used to compute 91 day to 3.5 year risk according to the CAD severity. Comparisons between patients with and without CAD were based on Cox-regression adjusted for age, sex, comorbidity, cardiovascular risk factors, concomitant cardiac medications, and post-CCTA treatment within 90 days. The composite endpoint occurred in 486 patients. Risk of the composite endpoint was 1.5% for patients without CAD, 6.8% for obstructive CAD, and 15% for three-vessel/left main disease. Compared with patients without CAD, higher relative risk of the composite endpoint was observed for non-obstructive CAD [hazard ratio (HR): 1.28; 95% confidence interval (CI): 1.01-1.63], obstructive one-vessel CAD (HR: 1.83; 95% CI: 1.37-2.44), two-vessel CAD (HR: 2.97; 95% CI: 2.09-4.22), and three-vessel/left main CAD (HR: 4.41; 95% CI :2.90-6.69). The results were consistent in strata of age, sex, and comorbidity. Conclusion: Coronary artery disease determined by CCTA in real-world practice predicts the 3.5 year composite risk of late revascularization, myocardial infarction, and all-cause death across different groups of age, sex, or comorbidity burden.

Invasively Measured Aortic Systolic Blood Pressure and Office Systolic Blood Pressure in Cardiovascular Risk Assessment: A Prospective Cohort Study.

Aortic systolic blood pressure (BP) represents the hemodynamic cardiac and cerebral burden more directly than office systolic BP. Whether invasively measured aortic systolic BP confers additional prognostic value beyond office BP remains debated. In this study, office systolic BP and invasively measured aortic systolic BP were recorded in 21 908 patients (mean age: 63 years; 58% men; 14% with diabetes mellitus) with stable angina pectoris undergoing elective coronary angiography during January 2001 to December 2012. Multivariate Cox models were used to assess the association with incident myocardial infarction, stroke, and death. Discrimination and reclassification were assessed using Harrell's C and the Continuous Net Reclassification Index. Data were analyzed with and without stratification by diabetes mellitus status. During a median follow-up period of 3.7 years (range: 0.1-10.8 years), 422 strokes, 511 myocardial infarctions, and 1530 deaths occurred. Both office and aortic systolic BP were associated with stroke in patients with diabetes mellitus (hazard ratio per 10 mm Hg, 1.18 [95% confidence interval, 1.07-1.30] and 1.14 [95% confidence interval, 1.05-1.24], respectively) and with myocardial infarction in patients without diabetes mellitus (hazard ratio, 1.07 [95% confidence interval, 1.02-1.12] and 1.05 [95% confidence interval, 1.01-1.10], respectively). In models including both BP measurements, aortic BP lost statistical significance and aortic BP did not confer improvement in either C-statistics or net reclassification analysis. In conclusion, invasively measured aortic systolic BP does not add prognostic information about cardiovascular outcomes and all-cause mortality compared with office BP in patients with stable angina pectoris, either with or without diabetes mellitus.

Coronary calcification among 3477 asymptomatic and symptomatic individuals.

BACKGROUND: Coronary artery calcification (CAC) can be detected by cardiac computed tomography (CT), is associated to cardiovascular risk, and common in asymptomatic individuals and patients referred for cardiac CT. DESIGN: CAC was evaluated in asymptomatic individuals and symptomatic patients referred for cardiac CT, to assess whether differences in CAC may be explained by symptoms or traditional cardiovascular risk factors. METHODS: The presence and extent of CAC, gender, family history of coronary artery disease, hypertension, hyperlipidaemia, diabetes and tobacco were compared in 1220 asymptomatic individuals aged 49-61 years and 2257 age-matched symptomatic patients referred for cardiac CT with suspected coronary artery disease. RESULTS: Symptomatic individuals had a higher frequency of a family history of coronary artery disease (46% vs. 23%, p < 0.001), hypertension (38% vs. 21%, p < 0.001), hyperlipidaemia (42% vs. 12%, p < 0.001), a trend for more diabetes (6% vs. 5%, p = 0.05), but no significant difference was observed for the presence of CAC (Agatston > 0; 45% vs. 45%, p = 0.94) or severe calcifications (Agatston > 400; 6% vs. 5%, p = 0.36). In multivariate analyses age (odds ratio (OR) 1.09-1.18), male gender (OR 3.5-6.43), hypertension (OR 1.42-1.79), hyperlipidaemia (OR 1.86-2.09) and tobacco use (OR 1.83-2.01) were predictors for the presence and extent of CAC, whereas symptoms were not predictive for the presence of (Agatston > 0, OR 0.70 (0.59-0.83)), mild (Agatston ≥ 10; OR 0.85 (0.71-1.02)), moderate (Agatston ≥ 100; OR 0.99 (0.79-1.24)) or severe calcifications (Agatston ≥ 400; OR 0.93 (0.65-1.33)). CONCLUSION: No difference in the presence or severity of coronary calcifications was observed between asymptomatic and symptomatic middle-aged individuals. After adjusting for cardiovascular risk factors, symptoms were not predictive for the presence or extent of CAC.

Patients With Suspected Coronary Artery Disease Referred for Examinations in the Era of Coronary Computed Tomography Angiography.

Invasive coronary angiography (ICA) is the gold standard in the diagnosis of coronary artery disease (CAD), however, associated with rare but severe complications. Patients with a high pretest risk should be referred directly for ICA, whereas a noninvasive strategy is recommended in the remaining patients. In the setting of a university hospital, we investigated the pattern of diagnostic tests used in daily clinical practice. During a 1-year period, consecutive patients with new symptoms suggestive of CAD and referred for exercise stress test, coronary computed tomography angiography (CCTA), single-photon emission computed tomography (SPECT), or ICA qualified for inclusion. The patients were followed for 1 year, and additional downstream diagnostic tests and need of coronary revascularization were registered. A total of 1,069 patients were included. A noninvasive test was the first examination in 797 patients (75%; exercise stress test in 37, CCTA in 450, and SPECT in 310), whereas 272 (25%) were referred directly to ICA. The ICA group had a significant higher pretest probability for CAD, and the percentage of patients with evidence of significant CAD was 31% (84 of 272 patients), whereas 18% (144 of 797 patients) in the noninvasive group (p <0.0001). In the comparison between CCTA and SPECT, there were no significant differences in downstream testing (16% [72 of 444 patients] vs 17% [53 of 310], p = 0.55), and revascularization rate (20% [14 of 69 patients with positive findings] vs 9% [6 of 67], p = 0.09). In conclusion, a noninvasive diagnostic test was chosen as the first test in 3 of 4 patients. Of the patients referred directly for noninvasive examination, 1/5 had significant CAD, whereas 1/3 of those for invasive examination.

The Western Denmark Cardiac Computed Tomography Registry: a review and validation study.

BACKGROUND: As a subregistry to the Western Denmark Heart Registry (WDHR), the Western Denmark Cardiac Computed Tomography Registry (WDHR-CCTR) is a clinical database established in 2008 to monitor and improve the quality of cardiac computed tomography (CT) in Western Denmark. OBJECTIVE: We examined the content, data quality, and research potential of the WDHR-CCTR. METHODS: We retrieved 2008-2012 data to examine the 1) content; 2) completeness of procedure registration using the Danish National Patient Registry as reference; 3) completeness of variable registration comparing observed vs expected numbers; and 4) positive predictive values as well as negative predictive values of 19 main patient and procedure variables. RESULTS: By December 31, 2012, almost 22,000 cardiac CTs with up to 40 variables for each procedure have been registered. Of these, 87% were coronary CT angiography performed in patients with symptoms indicative of coronary artery disease. Compared with the Danish National Patient Registry, the overall procedure completeness was 72%. However, an additional medical record review of 282 patients registered in the Danish National Patient Registry, but not in the WDHR-CCTR, showed that coronary CT angiographies accounted for only 23% of all nonregistered cardiac CTs, indicating >90% completeness of coronary CT angiographies in the WDHR-CCTR. The completeness of individual variables varied substantially (range: 0%-100%), but was >85% for more than 70% of all variables. Using medical record review of 250 randomly selected patients as reference standard, the positive predictive value for the 19 variables ranged from 89% to 100% (overall 97%), whereas the negative predictive value ranged from 97% to 100% (overall 99%). Stratification by center status showed consistently high positive and negative predictive values for both university (96%/99%) and nonuniversity centers (97%/99%). CONCLUSION: WDHR-CCTR provides ongoing prospective registration of all cardiac CTs performed in Western Denmark since 2008. Overall, the registry data have a high degree of completeness and validity, making it a valuable tool for clinical epidemiological research.

Soluble urokinase plasminogen activator receptor is in contrast to high-sensitive C-reactive-protein associated with coronary artery calcifications in healthy middle-aged subjects.

OBJECTIVE: The main objective of this study was to investigate the association between two markers of low-grade inflammation; soluble urokinase plasminogen activator receptor (suPAR) and high-sensitive C-reactive protein (hs-CRP); and coronary artery calcification (CAC) score detected by cardiac computed tomography (CT) scan. DESIGN: A cross sectional study of 1126 randomly sampled middle-aged men and women. METHODS: CAC score was measured by a non-contrast cardiac CT scan and total 10-year cardiovascular mortality risk was estimated using the Systematic Coronary Risk Evaluation (SCORE). Plasma samples were analysed for suPAR and hs-CRP. The association of suPAR and hs-CRP to CAC was evaluated by logistic regression analyses adjusting for categorised SCORE. The additive effect of suPAR to SCORE was evaluated by comparing area under curve (AUC) and net reclassification improvement (NRI). RESULTS: The odds of being in a higher CAC category, i.e. having more severe CAC, increased 16% (odds ratio (OR) 1.16, p = 0.02) when plasma suPAR concentration increased 1 ng/ml, and this was more pronounced in women (OR 1.30, p = 0.01) than in men (OR 1.15, p = 0.05). In comparison, hs-CRP was not associated with CAC category (OR 1.00, p = 0.90). When adding suPAR to categorised SCORE, AUC increased from 0.66 to 0.70 (p = 0.04) in women and from 0.65 to 0.68 (p = 0.03) in men. NRI was significant in men (NRI 19.3%, 95% CI 6.1-32.6, p = 0.004) as well as in women (NRI 20.8%, 95%CI 1.0-40.7, p = 0.04), without significant gender difference. CONCLUSIONS: suPAR, but not hs-CRP, appeared to be associated with CAC score independently of SCORE. The association was strongest in women.

Can osteoprotegerin be used to identify the presence and severity of coronary artery disease in different clinical settings?

PURPOSE: The biomarker Osteoprotegerin (OPG) is associated with coronary artery disease (CAD). The main purpose of this study was to evaluate the diagnostic value of OPG in healthy subjects and in patients with suspected angina pectoris (AP). METHODS: A total of 1805 persons were enrolled: 1152 healthy subjects and 493 patients with suspected AP. For comparison 160 patients with acute myocardial infarction (MI) were included. To uncover subclinical coronary atherosclerosis, a non-contrast cardiac-CT scan was performed in healthy subjects; while in patients with suspected AP a contrast coronary angiography was used to detect significant stenosis. OPG concentrations were analyzed and compared between groups. ROC-analyses were performed to estimate OPG cut-off values. RESULTS: OPG concentrations increased according to disease severity with the highest levels found in patients with acute MI. No significant difference (p = 0.97) in OPG concentrations was observed between subgroups of healthy subjects according to severity of coronary calcifications. A significant difference (p < 0.0001) in OPG concentrations was found between subgroups of patients with suspected stable AP according to severity of CAD. ROC-analysis showed an AUC of 0.62 (95% CI: 0.57-0.67). The optimal cut-off value of OPG (<2.29 ng/mL) had a sensitivity of 56.2% (95% CI: 49.2-63.0%) and a specificity of 62.9% (95% CI: 57.3-68.2%). CONCLUSION: OPG cannot be used to differentiate between healthy subjects with low versus high levels of coronary calcifications. In patients with suspected AP a single OPG measurement is of limited use in the diagnosis of CAD.

Lipocalin-type prostaglandin D synthase is not a biomarker of atherosclerotic manifestations.

OBJECTIVE: Over the last decades Lipocalin-type prostaglandin D synthase (L-PGDS), Osteoprotegerin (OPG), Osteopontin (OPN) and Pregnancy associated plasma protein A (PAPP-A) have been reported to be associated with coronary artery disease, and L-PGDS has been proposed as a potential new diagnostic tool in the setting of stable coronary artery disease. We set out to investigate if measurement of concentrations of these biomarkers could be used to differentiate between four groups of individuals with different atherosclerotic manifestations. METHODS: A total of 120 individuals from four equal gender- and age-matched groups were studied: (i) no previous cardiovascular disease (CVD) and no coronary calcifications [CAC-negative group], (ii) no previous CVD but evidence of severe coronary calcifications [CAC-positive group], (iii) acute coronary syndrome [ACS-group], and (iv) clinical stable patients with CVD, who were referred for cardiovascular surgery [CVD-group]. Concentrations of L-PGDS, OPG, OPN and PAPP-A were analyzed and compared between the four groups. RESULTS: We did not find any significant differences in L-PGDS concentrations between the four groups (p = 0.32). OPG concentrations differed significantly (p = 0.003), with the highest concentration observed in ACS patients. Considering OPN (p = 0.12) and PAPP-A (p = 0.53) their concentrations between groups did not differ significantly. CONCLUSION: The main message from this study is the observation that L-PGDS based on a single blood test appears to be less valuable than previously proposed in identification of patients with coronary artery disease. However, ACS patients have higher OPG concentrations than patients with different manifestations of stable atherosclerosis. Neither OPN nor PAPP-A concentrations differed between groups.

Localization of microfibrillar-associated protein 4 (MFAP4) in human tissues: clinical evaluation of serum MFAP4 and its association with various cardiovascular conditions.

Microfibrillar-associated protein 4 (MFAP4) is located in the extracellular matrix (ECM). We sought to identify tissues with high levels of MFAP4 mRNA and MFAP4 protein expression. Moreover, we aimed to evaluate the significance of MFAP4 as a marker of cardiovascular disease (CVD) and to correlate MFAP4 with other known ECM markers, such as fibulin-1, osteoprotegerin (OPG), and osteopontin (OPN). Quantitative real-time PCR demonstrated that MFAP4 mRNA was more highly expressed in the heart, lung, and intestine than in other elastic tissues. Immunohistochemical studies demonstrated high levels of MFAP4 protein mainly at sites rich in elastic fibers and within blood vessels in all tissues investigated. The AlphaLISA technique was used to determine serum MFAP4 levels in a clinical cohort of 172 patients consisting of 5 matched groups with varying degrees of CVD: 1: patients with ST elevation myocardial infarction (STEMI), 2: patients with non-STEMI, 3: patients destined for vascular surgery because of various atherosclerotic diseases (stable atherosclerotic disease), 4: apparently healthy individuals with documented coronary artery calcification (CAC-positive), and 5: apparently healthy individuals without signs of coronary artery calcification (CAC-negative). Serum MFAP4 levels were significantly lower in patients with stable atherosclerotic disease than CAC-negative individuals (p<0.05). Furthermore, lower serum MFAP4 levels were present in patients with stable atherosclerotic disease compared with STEMI and non-STEMI patients (p<0.05). In patients with stable atherosclerotic disease, positive correlations between MFAP4 and both fibulin-1 (ρ = 0.50; p = 0.0244) and OPG (ρ = 0.62; p = 0.0014) were found. Together, these results indicate that MFAP4 is mainly located in elastic fibers and is highly expressed in blood vessels. The present study suggests that serum MFAP4 varies in groups of patients with different cardiovascular conditions. Further studies are warranted to describe the role of serum MFAP4 as a biomarker of stable atherosclerotic disease.

Discrepancy between coronary artery calcium score and HeartScore in middle-aged Danes: the DanRisk study.

BACKGROUND: Coronary artery calcification (CAC) is an independent and incremental risk marker. This marker has previously not been compared to the HeartScore risk model. DESIGN: A random sample of 1825 citizens (men and women, 50 or 60 years of age) was invited for screening. METHODS: Using the HeartScore model, the 10-year risk of fatal cardiovascular events based on gender, age, smoking, systolic blood pressure, and total cholesterol was estimated. A low risk was defined as <5%. The CAC score was calculated from a non-contrast enhanced cardiac-CT scan and given in Agatston U. RESULTS: A total of 1257 (69%) of the invited subjects were interested in the screening. Due to previous cardiovascular disease or diabetes mellitus, 101 were excluded. Of the remaining 1156, 47% were men and 53% women; one half were 50 years old and the other half 60 years old. A low HeartScore was found in 901 of which 334 (37%) had CAC. A high HeartScore was recorded in 251 of which 80 (32%) did not have any CAC. High HeartScores and CAC were significantly more common in males than females. CONCLUSIONS: CAC is common in healthy middle-aged Danes with a low HeartScore, and, on the contrary, high-risk subjects very frequently do not have CAC. The therapeutic and prognostic implications of these observations remain to be clarified.

Risk stratification of patients suspected of coronary artery disease: comparison of five different models.

OBJECTIVE: To compare the performance of five risk models (Diamond-Forrester, the updated Diamond-Forrester, Morise, Duke, and a new model designated COronary Risk SCORE (CORSCORE) in predicting significant coronary artery disease (CAD) in patients with chest pain suggestive of stable angina pectoris. METHODS: Retrospective cohort for creation of CORSCORE by means of logistic regression analysis. Prospective cohort for validation of the five risk models using receiver operating characteristics (ROC) curve analysis, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Significant CAD was defined as lumen area diameter reduction ≥50% at coronary angiography. All risk models include information on age, sex, and symptoms. In addition the Duke, Morise, and CORSCORE models include information on tobacco use and hypercholesterolemia. Duke and Morise also include information on diabetes. History of myocardial infarction is used by the Duke and CORSCORE models whereas hypertension is included in the Morise and CORSCORE models. The Duke model includes information on electrocardiogram (ECG) changes and the Morise model includes information on family history, body mass index, obesity, and oestrogen status. RESULTS: 4781 retrospective and 633 prospective consecutive patients referred for coronary angiography were included. The area under the ROC for the updated Diamond-Forrester, Duke, and CORSCORE was significantly larger than for the Diamond-Forrester (p≤0.001). The IDI was significantly higher for the Duke as compared to all other models (p≤0.006). CONCLUSION: The Duke, updated Diamond-Forrester, and CORSCORE risk models are most efficient in predicting CAD in a contemporary cohort of patients with symptoms suggestive of angina. The updated Diamond-Forrester may most operational in daily clinical practice since it is calculated from the lowest number of clinical variables.

Influence of coronary computed tomographic angiography on patient treatment and prognosis in patients with suspected stable angina pectoris.

We evaluated the influence of coronary computed tomographic angiography (CTA) as a first-line diagnostic test on patient treatment and prognosis. A total of 1,055 consecutive patients with suspected stable angina pectoris (mean age 55 ± 10 years, 56% women) and a low to intermediate pretest likelihood of coronary artery disease (CAD) were included in the present study. The patients were followed for a median of 18 months. The use of downstream diagnostic testing and medical therapy after CTA were recorded. The CTA result was normal in 49%, and nonobstructive and obstructive CAD (≥50% stenosis) was demonstrated in 31% and 15% of the patients, respectively. Coronary CTA was inconclusive in 5% of the patients. The use of antiplatelet therapy decreased with normal findings from CTA, and the use of antiplatelet and lipid-lowering agents increased in patients with CAD. Additional testing was performed in 2% of patients with normal CTA findings and in 7% and 82% of patients with nonobstructive or obstructive CAD, respectively. No patients without CAD, 0.9% of patients with nonobstructive CAD, and 1.9% of patients with obstructive CAD met the primary end point (cardiovascular death and myocardial infarction, p = 0.008). No patients without CAD, 1.5% of patients with nonobstructive CAD, and 30% patients with obstructive CAD met the secondary end point (cardiovascular death, myocardial infarction, and coronary revascularization, p <0.0001). In conclusion, in patients suspected of having angina, the findings from CTA influence patient treatment without resulting in excessive additional testing. Coronary CTA provides important prognostic information, with excellent intermediate-term outcomes in patients with normal CTA findings.

Coronary computed tomographic angiography in patients suspected of coronary artery disease: impact of observer experience on diagnostic performance and interobserver reproducibility.

BACKGROUND: A high diagnostic performance of coronary computed tomographic angiography (CTA) in identifying coronary artery disease (CAD) has been shown in experienced high-volume centers. Whether this may be accomplished in centers with less CTA experience remains unknown. OBJECTIVES: We determined the diagnostic performance and interobserver reproducibility of CTA in detecting significant CAD in a center with limited experience. METHODS: In 209 patients, CTA was performed with 64-slice or dual-source CT technology, and analyses were performed independently by 2 inexperienced observers. Significant CAD by CTA was defined as >/=1 stenoses >/=50% or >/=1 nonevaluable segment, whereas significant CAD by invasive quantitative coronary angiography was defined as >/=1 stenoses >/=50%. We evaluated the influence of CAD pretest probability, Agatston score (AS), heart rate (HR), and observer experience on the diagnostic sensitivity, specificity, positive (PPV) and negative predictive values (NPV), interobserver reproducibility, and duration of CTA analysis. RESULTS: Per-patient (CAD prevalence, 35%) sensitivity was 88%-99%, specificity was 78%-82%, PPV was 68%-74%, and NPV was 92%-99%. Overall interobserver reproducibility was good (kappa = 0.65). A significant temporal improvement was observed in diagnostic specificity (observer A: 68%-89%, P = 0.007; observer B: 71%-89%, P = 0.02), and interobserver reproducibility (kappa = 0.35-0.89, P = 0.01) during the study period. Duration of analysis decreased during the study period and was positively associated with CAD pretest probability and AS. CONCLUSIONS: Suboptimal diagnostic performance and interobserver reproducibility must be anticipated during CTA implementation. A high diagnostic sensitivity, specificity, and interobserver reproducibility were achieved after a large number of studies performed with the state-of-the-art scanner technology.

Comparison of usefulness of exercise testing versus coronary computed tomographic angiography for evaluation of patients suspected of having coronary artery disease.

In patients suspected of having coronary artery disease (CAD), we compared the diagnostic sensitivity and specificity of exercise testing using ST-segment changes alone and ST-segment changes, angina pectoris, and hemodynamic variables compared to coronary computed tomographic angiography (CTA). Quantitative invasive coronary angiography was the reference method (>50% coronary lumen reduction). A positive exercise test was defined as the development of significant ST-segment changes (> or =1 mV measured 80 ms from the J-point), and the occurrence of one or more of the following criteria: ST-segment changes > or =1 mV measured 80 ms from the J-point, angina pectoris, ventricular arrhythmia (the occurrence of > or =3 premature ventricular beats), and > or =20 mm Hg decrease in systolic blood pressure during the test. Positive results on CTA were defined as a coronary lumen reduction of > or =50%. In 100 patients (61 +/- 9 years old, 50% men, and 29% prevalence of significant CAD), the diagnostic sensitivity and specificity of exercise testing using ST-segment changes was 45% (95% confidence interval 53% to 87%) and 63% (95% confidence interval 61% to 84%), respectively. However, the inclusion of all test variables yielded a sensitivity of 72% (95% confidence interval 53% to 87%) and a specificity of 37% (95% confidence interval 26% to 49%). The diagnostic sensitivity of 97% (95% confidence interval 82% to 100%) and specificity of 80% (95% confidence interval 69% to 89%) for CTA, however, were superior to any of the exercise test analysis strategies. In conclusion, in patients suspected of having CAD, the diagnostic sensitivity of exercise testing significantly improves if all test variables are included compared to using ST-segment changes exclusively. Furthermore, the superior diagnostic performance of CTA for the detection and exclusion of significant CAD might favor CTA as the first-line diagnostic test in patients suspected of having CAD.

[Cardiac computer tomography in the investigation of atypical chest pain]. / Hjertecomputertomografi til udredning for atypiske brystsmerter.

INTRODUCTION: Coronary CT angiography (CTA) is a promising method used for diagnostic evaluation of patients suspected of coronary artery disease (CAD). CTA is increasingly used as an alternative to conventional coronary angiography. Information on the diagnostic and therapeutic consequences of using CTA in the diagnostic work-up of patients suspected of CAD is sparse. MATERIAL AND METHODS: Out-clinic patients (n = 215) with chest pain and an intermediate pre-test probability of CAD were referred to diagnostic evaluation by CTA. RESULTS: CTA was not performed in 5% (11/215) due to extensive coronary calcification or arrhythmia, was non-conclusive in 7% (15/215) and was diagnostic in 88% (189/215) of the patients. CTA excluded CAD in 46% (99/215) of the patients. No further diagnostic or hospital follow-up after CTA was necessary in 73% (156/215) of the patients. CTA identified non-significant CAD in 27% (57/215) and significant CAD (>or= 50% stenosis) in 15% (33/215) of the patients. The proportion of patients with CAD in relevant antithrombotic and lipid-lowering medication increased following CTA. Further diagnostic evaluation with coronary angiography following CTA was indicated in 18% (39/215) of the patients due to obstructive CAD (n = 21), non-diagnostic examination (n = 7), or the presence of extensive coronary calcification or arrhythmia (n = 11). CONCLUSION: CTA ruled-out CAD in 46% of the patients. No further diagnostic testing or hospital follow-up after CTA was necessary in 73% of the patients. CTA seems valuable in excluding CAD, and may prevent unnecessary invasive angiography in patients without CAD.

Long genuine coronary artery lesions treated with stiff tubular or flexible coiled stents. A randomized angiographic follow-up study.

OBJECTIVE: To investigate effects of stent flexibility on 6 months' clinical and angiographic outcome in long stented lesions. DESIGN: A total of 44 genuine coronary artery lesions (lesion length >20 mm and < or =30 mm) were randomized to implantation with a 30 mm long flexible coiled stainless steel stent (Freedom Force, Global Therapeutics) (n = 23) or a 30 mm long stiff tubular stainless steel stent (Crown, Johnson & Johnson) (n = 21). RESULTS: Target vessel revascularization was performed in 10 patients (45%) in the Freedom Force stent group, and in 7 patients (33%) in the Crown stent group (ns). No significant differences concerning minimum lumen diameter (MLD), early gain, late loss or binary restenosis rate were seen. In the Freedom Force stent group all restenoses were located within the stent. In the Crown stent group three (27%) of the restenoses were located at the edge of the stent (ns). CONCLUSION: In a limited number of patients no significant differences could be detected in clinical or angiographic parameters between patients treated with long tubular or long coiled stents.