Publications by authors named "Admir Dedic"

34 Publications

Coronary CT angiography for improved assessment of patients with acute chest pain and low-range positive high-sensitivity troponins: study protocol for a prospective, observational, multicentre study (COURSE trial).

BMJ Open 2021 10 18;11(10):e049349. Epub 2021 Oct 18.

Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands.

Introduction: Current evaluation of patients suspected of a non-ST-elevation acute coronary syndrome (NSTE-ACS) involves the use of algorithms that incorporate clinical information, electrocardiogram (ECG) and high-sensitivity cardiac troponins (hs-troponins). While primarily designed to rule out NSTE-ACS safely, these algorithms can also be used for rule in of NSTE-ACS in some patients. Still, in a substantial number of patients, these algorithms do not provide a conclusive work-up. These patients often present with an atypical clinical profile and low-range positive hs-troponin values without a characteristic rise or fall pattern. They represent a heterogeneous group of patients with various underlying conditions; only a fraction (30%-40%) will eventually be diagnosed with a myocardial infarction. Uncertainty exists about the optimal diagnostic strategy and their management depends on the clinical perspective of the treating physician ranging from direct discharge to admission for invasive coronary angiography. Coronary CT angiography (CCTA) is a non-invasive test that has been shown to be safe, fast and reliable in the evaluation of coronary artery disease. In this study, we will determine the usefulness of CCTA in patients with acute chest pain and low-range positive hs-troponin values.

Methods And Analysis: A prospective, double-blind, observational, multicentre study conducted in the Netherlands. Patients aged 30-80 years presenting to the emergency department with acute chest pain and a suspicion of NSTE-ACS, a normal or non-diagnostic ECG and low-range positive hs-troponins will be scheduled to undergo CCTA. The primary outcome is the diagnostic accuracy of CCTA for the diagnosis of NSTE-ACS at discharge, in terms of sensitivity and negative predictive value.

Ethics And Dissemination: This study was approved by the Medical Research Ethics Committee of Erasmus Medical Center in Rotterdam, the Netherlands (registration number MEC-2017-506). Written informed consent to participate will be obtained from all participants. This study's findings will be published in a peer-reviewed journal.

Trial Registration Number: ClinicalTrials.gov (NCT03129659).
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http://dx.doi.org/10.1136/bmjopen-2021-049349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524275PMC
October 2021

Dynamic Myocardial Perfusion CT for the Detection of Hemodynamically Significant Coronary Artery Disease.

JACC Cardiovasc Imaging 2021 Sep 8. Epub 2021 Sep 8.

Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Stanford University School of Medicine and Cardiovascular Institute, Stanford, California, USA. Electronic address:

Objectives: In this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR).

Background: CT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies.

Methods: At 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of ≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics.

Results: ICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with ≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95% CI: 91-100), 72% (95% CI: 66-78), and 78% (95% CI: 73-83), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95% CI: 75-92) but higher specificity (89%; 95% CI: 85-93) and accuracy (88%; 95% CI: 84-92). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95% CI: 0.71-0.86) and 0.82 (95% CI: 0.74-0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively.

Conclusions: Dynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795).
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http://dx.doi.org/10.1016/j.jcmg.2021.07.021DOI Listing
September 2021

Pressure-Volume Loop Analysis in Percutaneous Coronary Intervention-Induced Shock.

JACC Case Rep 2020 Oct 23;2(12):1882-1883. Epub 2020 Sep 23.

Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.

High-risk percutaneous coronary intervention may lead to undesirable clinical scenarios such as cardiogenic shock. We describe the hemodynamic changes using pressure-volume loop analyses in percutaneous coronary intervention-induced shock. (PULsecath mechanicaL Support Evaluation [PULSE]; NCT03200990) ().
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http://dx.doi.org/10.1016/j.jaccas.2020.07.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299126PMC
October 2020

Up-Front Noninvasive Imaging in Low-Risk NSTEMI: An Old Keeper at a New Gate.

J Am Coll Cardiol 2019 11;74(20):2478-2479

Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona.

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http://dx.doi.org/10.1016/j.jacc.2019.06.082DOI Listing
November 2019

HEART score improves efficiency of coronary computed tomography angiography in patients suspected of acute coronary syndrome in the emergency department.

Eur Heart J Acute Cardiovasc Care 2020 Feb 24;9(1):23-29. Epub 2019 Oct 24.

Department of Cardiology, Erasmus Medical Centre, The Netherlands.

Aims: Coronary computed tomography angiography is increasingly employed in the emergency department for suspected acute coronary syndrome patients. The HEART score has been proposed for initial risk stratification in these patients. The aim of this study was to investigate the diagnostic value and efficiency of the HEART score before coronary computed tomography angiography.

Methods And Results: We included patients suspected of acute coronary syndrome who underwent coronary computed tomography angiography in the emergency department. Based on the HEART score, patients were stratified as low-risk (HEART≤3), intermediate-risk (HEART4-6) and high-risk (HEART≥7). We assessed coronary computed tomography angiography for the presence of significant coronary artery disease (>50% stenosis). The primary outcome, the level of major adverse cardiac events, was a composite endpoint of all-cause mortality, acute coronary syndrome or coronary revascularisation within 30 days. The study population consisted of 340 patients (mean age: 55.6±10.1 years, 44.7% women), major adverse cardiac events occurred in 45 (13.2%) patients. The incidence of major adverse cardiac events in patients stratified as low-risk (35.0%), intermediate-risk (56.8%) and high-risk (8.2%) was 3.4%, 12.4% and 60.7%, respectively. All four low-risk patients with major adverse cardiac events had a HEART score of three. An algorithm where coronary computed tomography angiography is reserved for patients with HEART 3-6 resulted in a sensitivity of 97.8%, specificity of 84.1%, negative predictive value of 99.6% and positive predictive value of 48.4%, while reducing the need for coronary computed tomography angiography by 22% (=75).

Conclusion: The predictive value of coronary computed tomography angiography for 30-day major adverse cardiac events in suspected acute coronary syndrome patients is good, and reserving coronary computed tomography angiography for HEART score 3-6 patients reduces the number of needed coronary computed tomography angiograms without affecting diagnostic accuracy.
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http://dx.doi.org/10.1177/2048872619882424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008554PMC
February 2020

Round-the-clock performance of coronary CT angiography for suspected acute coronary syndrome: Results from the BEACON trial.

Eur Radiol 2018 May 15;28(5):2169-2175. Epub 2017 Dec 15.

Department of Cardiology, Erasmus University Medical Center, Room: Ca-207a, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands.

Objective: To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours.

Methods: Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3.

Results: There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0-33.5] for patients presenting during office hours in comparison to 27.5 [19.75-32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0-1.0] vs. 1.0 [0-4.0], p=0.009).

Conclusion: Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished.

Key Points: • Quality scores were higher for coronary-CTA during office hours. • There were no differences in acquisition parameters. • There was a non-significant trend towards higher heart rates outside office hours. • Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff. • Coronary-CTA on the ED needs preparation time and optimisation of the procedure.
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http://dx.doi.org/10.1007/s00330-017-5082-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5882623PMC
May 2018

Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain: Subanalysis of the Multicenter, Randomized CRESCENT Trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease).

Circ Cardiovasc Imaging 2017 Feb;10(2)

From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).

Background: Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency.

Methods And Results: The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (P interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (P interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all P interactions≥0.097).

Conclusions: Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01393028.
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http://dx.doi.org/10.1161/CIRCIMAGING.116.005295DOI Listing
February 2017

Is there still a role for cardiac CT in the emergency department in the era of highly-sensitive troponins?

Minerva Cardioangiol 2017 Jun 25;65(3):214-224. Epub 2016 Nov 25.

Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA -

Physicians practicing cardiovascular medicine are every day confronted with patients presenting with symptoms suggestive of an acute coronary syndrome (ACS). Over the years, there have been substantial technical advances, such as the introduction of new non-invasive imaging techniques and the introduction of new highly sensitive cardiac biomarkers. Physicians have adopted these new assets and have become more experienced with them thus improving medical care. Nevertheless, the search for an efficient, yet safe diagnostic work-up for patients presenting with symptoms suggestive of ACS is ongoing. A large proportion of patients will require some form of non-invasive testing and the choice for the diagnostic modality as well as its timing are important steps in this process. Cardiac computed tomography (CT), a non-invasive imaging technique that rapidly provides visualization of the coronary artery tree, is an attractive option, with its unparalleled negative predictive value for obstructive coronary artery disease (CAD). With the introduction of highly-sensitive troponins (hsTn), the role of non-invasive testing, including cardiac CT, has changed. This review will provide an oversight on what is known about cardiac CT in acute chest presentations. Furthermore, we will discuss the changing role of cardiac CT in the era of hsTn and the possibility of their combined use in the work-up of suspected ACS patients. hsTn is currently an established tool for the diagnosis and triage of patients with suspected ACS. The role of cardiac CT has shifted now to a secondary, comprehensive rule-out test in patients with inconclusive biomarker status, providing information on stenosis severity, plaque burden, high-risk features and the presence of other serious conditions that can also give rise to hsTn.
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http://dx.doi.org/10.23736/S0026-4725.16.04291-2DOI Listing
June 2017

Diagnostic value of transmural perfusion ratio derived from dynamic CT-based myocardial perfusion imaging for the detection of haemodynamically relevant coronary artery stenosis.

Eur Radiol 2017 Jun 4;27(6):2309-2316. Epub 2016 Oct 4.

Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.

Objectives: To investigate the additional value of transmural perfusion ratio (TPR) in dynamic CT myocardial perfusion imaging for detection of haemodynamically significant coronary artery disease compared with fractional flow reserve (FFR).

Methods: Subjects with suspected or known coronary artery disease were prospectively included and underwent a CT-MPI examination. From the CT-MPI time-point data absolute myocardial blood flow (MBF) values were temporally resolved using a hybrid deconvolution model. An absolute MBF value was measured in the suspected perfusion defect. TPR was defined as the ratio between the subendocardial and subepicardial MBF. TPR and MBF results were compared with invasive FFR using a threshold of 0.80.

Results: Forty-three patients and 94 territories were analysed. The area under the receiver operator curve was larger for MBF (0.78) compared with TPR (0.65, P = 0.026). No significant differences were found in diagnostic classification between MBF and TPR with a territory-based accuracy of 77 % (67-86 %) for MBF compared with 70 % (60-81 %) for TPR. Combined MBF and TPR classification did not improve the diagnostic classification.

Conclusions: Dynamic CT-MPI-based transmural perfusion ratio predicts haemodynamically significant coronary artery disease. However, diagnostic performance of dynamic CT-MPI-derived TPR is inferior to quantified MBF and has limited incremental value.

Key Points: • The transmural perfusion ratio from dynamic CT-MPI predicts functional obstructive coronary artery disease • Performance of the transmural perfusion ratio is inferior to quantified myocardial blood flow • The incremental value of the transmural perfusion ratio is limited.
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http://dx.doi.org/10.1007/s00330-016-4567-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408049PMC
June 2017

[Coronary artery calcium score in clinical practice].

Ned Tijdschr Geneeskd 2016 ;160:A9979

Amphia Ziekenhuis, afd. Cardiologie, Breda.

Since the beginning of the 1990s it is possible to obtain images of the heart using CT technology to visualise coronary calcifications. The amount of coronary calcification can be quantified with a coronary artery calcium score. Today, there is sufficient scientific evidence that justifies the use of the coronary artery calcium score in selected patients. In asymptomatic patients, the coronary artery calcium score can be used for more precise and tailored risk stratification for the occurrence of future cardiovascular events. The absence of coronary calcification is associated with a good prognosis. In addition, the coronary artery calcium score can also be used as the initial test in symptomatic patients, to dictate treatment strategies going forward.
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December 2016

Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study.

J Am Coll Cardiol 2016 Jan;67(1):16-26

Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.

Background: It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).

Objectives: This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.

Methods: In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.

Results: The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.

Conclusions: CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).
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http://dx.doi.org/10.1016/j.jacc.2015.10.045DOI Listing
January 2016

Prognostic Value of Coronary Computed Tomography Imaging in Patients at High Risk Without Symptoms of Coronary Artery Disease.

Am J Cardiol 2016 Mar 14;117(5):768-74. Epub 2015 Dec 14.

Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands.

At present, traditional risk factors are used to guide cardiovascular management of asymptomatic subjects. Intensified surveillance may be warranted in those identified as high risk of developing cardiovascular disease (CVD). This study aims to determine the prognostic value of coronary computed tomography (CT) angiography (CCTA) next to the coronary artery calcium score (CACS) in patients at high CVD risk without symptoms suspect for coronary artery disease (CAD). A total of 665 patients at high risk (mean age 56 ± 9 years, 417 men), having at least one important CVD risk factor (diabetes mellitus, familial hypercholesterolemia, peripheral artery disease, or severe hypertension) or a calculated European systematic coronary risk evaluation of >10% were included from outpatient clinics at 2 academic centers. Follow-up was performed for the occurrence of adverse events including all-cause mortality, nonfatal myocardial infarction, unstable angina, or coronary revascularization. During a median follow-up of 3.0 (interquartile range 1.3 to 4.1) years, adverse events occurred in 40 subjects (6.0%). By multivariate analysis, adjusted for age, gender, and CACS, obstructive CAD on CCTA (≥50% luminal stenosis) was a significant predictor of adverse events (hazard ratio 5.9 [CI 1.3 to 26.1]). Addition of CCTA to age, gender, plus CACS, increased the C statistic from 0.81 to 0.84 and resulted in a total net reclassification index of 0.19 (p <0.01). In conclusion, CCTA has incremental prognostic value and risk reclassification benefit beyond CACS in patients without CAD symptoms but with high risk of developing CVD.
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http://dx.doi.org/10.1016/j.amjcard.2015.11.058DOI Listing
March 2016

Coronary CT angiography derived fractional flow reserve: Methodology and evaluation of a point of care algorithm.

J Cardiovasc Comput Tomogr 2016 Mar-Apr;10(2):105-13. Epub 2015 Dec 18.

Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.

Background: Recently several publications described the diagnostic value of coronary CT angiography (coronary CTA) derived fractional flow reserve (CTA-FFR). For a recently introduced on-site CTA-FFR application, detailed methodology and factors potentially affecting performance have not yet been described.

Objective: To provide a methodological background for an on-site CTA-FFR application and evaluate the effect of patient and acquisition characteristics.

Methods: The on-site CTA-FFR application utilized a reduced-order hybrid model applying pressure drop models within stenotic regions. In 116 patients and 203 vessels the diagnostic performance of CTA-FFR was investigated using invasive FFR measurements as a reference. The effect of several potentially relevant factors on CTA-FFR was investigated.

Results: 90 vessels (44%) had a hemodynamically relevant stenosis according to invasive FFR (threshold ≤0.80). The overall vessel-based sensitivity, specificity and accuracy of CTA-FFR were 88% (CI 95%:79-94%), 65% (55-73%) and 75% (69-81%). The specificity was significantly lower in the presence of misalignment artifacts (25%, CI: 6-57%). A non-significant reduction in specificity from 74% (60-85%) to 48% (26-70%) was found for higher coronary artery calcium scores. Left ventricular mass, diabetes mellitus and large vessel size increased the discrepancy between invasive FFR and CTA-FFR values.

Conclusions: On-site calculation of CTA-FFR can identify hemodynamically significant CAD with an overall per-vessel accuracy of 75% in comparison to invasive FFR. The diagnostic performance of CTA-FFR is negatively affected by misalignment artifacts. CTA-FFR is potentially affected by left ventricular mass, diabetes mellitus and vessel size.
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http://dx.doi.org/10.1016/j.jcct.2015.12.006DOI Listing
December 2016

Calcium imaging and selective computed tomography angiography in comparison to functional testing for suspected coronary artery disease: the multicentre, randomized CRESCENT trial.

Eur Heart J 2016 Apr 7;37(15):1232-43. Epub 2016 Jan 7.

Department of Cardiology, Erasmus Medical Center, Room Ca-207a, s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.

Aims: To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD).

Methods And Results: Between April 2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6 ± 8.7 vs. 6.1 ± 9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (€369 vs. €440; P < 0.0001).

Conclusion: For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing. Incorporating the calcium scan into the diagnostic workup was safe and lowered diagnostic expenses and radiation exposure.
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http://dx.doi.org/10.1093/eurheartj/ehv700DOI Listing
April 2016

Increased Aortic Valve Calcification in Familial Hypercholesterolemia: Prevalence, Extent, and Associated Risk Factors.

J Am Coll Cardiol 2015 Dec;66(24):2687-2695

Department of Internal Medicine, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands.

Background: Familial hypercholesterolemia is typically caused by LDL receptor (LDLR) mutations that result in elevated levels of LDL cholesterol (LDL-C). In homozygous FH, the prevalence of aortic valve calcification (AoVC) reaches 100% and is often symptomatic.

Objectives: The objective of this study was to investigate the prevalence, extent, and risk-modifiers of AoVC in heterozygous FH (he-FH) that are presently unknown.

Methods: Asymptomatic patients with he-FH and 131 non-familial hypercholesterolemia controls underwent CT computed tomography calcium scoring. AoVC was defined as the presence of calcium at the aortic valve leaflets. The extent of AoVC was expressed in Agatston units, as the AoVC-score. We compared the prevalence and extent of AoVC between cases and controls. In addition, we investigated risk modifiers of AoVC, including the presence of LDLR mutations without residual function (LDLR-negative mutations), maximum untreated LDL-cholesterol (maxLDL), LDL-C, blood pressure, and coronary artery calcification (CAC).

Results: We included 145 asymptomatic patients with he-FH (93 men; mean age 52 ± 8 years) and 131 non-familial hypercholesterolemia controls. The prevalence (%) and AoVC-score (median, IQR) were higher in he-FH patients than in controls: 41%, 51 (9-117); and 21%, 21 (3-49) (p < 0.001 and p = 0.007). Age, untreated maxLDL, CAC, and diastolic blood pressure were independently associated with AoVC. LDLR-negative mutational he-FH was the strongest predictor of the AoVC-score (OR: 4.81; 95% CI: 2.22 to 10.40; p = <0.001).

Conclusions: Compared to controls, he-FH is associated with a high prevalence and a large extent of subclinical AoVC, especially in patients with LDLR-negative mutations, highlighting the critical role of LDL-C metabolism in AoVC etiology.
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http://dx.doi.org/10.1016/j.jacc.2015.09.087DOI Listing
December 2015

Fractional flow reserve computed from noninvasive CT angiography data: diagnostic performance of an on-site clinician-operated computational fluid dynamics algorithm.

Radiology 2015 Mar 13;274(3):674-83. Epub 2014 Oct 13.

From the Departments of Radiology (A.C., M.M.L., A. Kurata, A.Kono, A.D., R.G.C., M.L.D., M.O., R.J.M.v.G, K.N.) and Cardiology (A.C., M.M.L., A.D., R.G.C., F.J.G., R.J.M.v.G., K.N.), Erasmus University Medical Center, 's-Gravendijkwal 230, Rotterdam 3015 CE, the Netherlands.

Purpose: To validate an on-site algorithm for computation of fractional flow reserve (FFR) from coronary computed tomographic (CT) angiography data against invasively measured FFR and to test its diagnostic performance as compared with that of coronary CT angiography.

Materials And Methods: The institutional review board provided a waiver for this retrospective study. From coronary CT angiography data in 106 patients, FFR was computed at a local workstation by using a computational fluid dynamics algorithm. Invasive FFR measurement was performed in 189 vessels (80 of which had an FFR ≤ 0.80); these measurements were regarded as the reference standard. The diagnostic characteristics of coronary CT angiography-derived computational FFR, coronary CT angiography, and quantitative coronary angiography were evaluated against those of invasively measured FFR by using C statistics. Sensitivity and specificity were compared by using a two-sided McNemar test.

Results: For computational FFR, sensitivity was 87.5% (95% confidence interval [CI]: 78.2%, 93.8%), specificity was 65.1% (95% CI: 55.4%, 74.0%), and accuracy was 74.6% (95% CI: 68.4%, 80.8%), as compared with the finding of lumen stenosis of 50% or greater at coronary CT angiography, for which sensitivity was 81.3% (95% CI: 71.0%, 89.1%), specificity was 37.6% (95% CI: 28.5%, 47.4%), and accuracy was 56.1% (95% CI: 49.0%, 63.2%). C statistics revealed a larger area under the receiver operating characteristic curve (AUC) for computational FFR (AUC, 0.83) than for coronary CT angiography (AUC, 0.64). For vessels with intermediate (25%-69%) stenosis, the sensitivity of computational FFR was 87.3% (95% CI: 76.5%, 94.3%) and the specificity was 59.3% (95% CI: 47.8%, 70.1%).

Conclusion: With use of a reduced-order algorithm, computation of the FFR from coronary CT angiography data can be performed locally, at a regular workstation. The diagnostic accuracy of coronary CT angiography-derived computational FFR for the detection of functionally important coronary artery disease (CAD) was good and was incremental to that of coronary CT angiography within a population with a high prevalence of CAD.
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http://dx.doi.org/10.1148/radiol.14140992DOI Listing
March 2015

Prognostic implications of non-culprit plaques in acute coronary syndrome: non-invasive assessment with coronary CT angiography.

Eur Heart J Cardiovasc Imaging 2014 Nov 17;15(11):1231-7. Epub 2014 Jun 17.

Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands.

Aims: Non-culprit plaques are responsible for a substantial number of future events in patients with acute coronary syndrome (ACS). In this study, we evaluated the prognostic implications of non-culprit plaques seen on coronary computed tomography angiography (CTA) in patients with ACS.

Methods And Results: Coronary CTA was performed in 169 patients (mean 59 ± 11 years, 129 males) admitted with ACS. Data sets were assessed for the presence of obstructive non-culprit plaques (>50% luminal narrowing), segment involvement score, and quantitative measures of plaque burden, after censoring initial culprit plaques. Follow-up was performed for the occurrence of major adverse cardiovascular events (MACEs) unrelated to the initial culprit plaque; cardiac death, second ACS, or coronary revascularization after 90 days. After a median follow-up of 4.8 (IQR 2.6-6.6) years, MACE occurred in 36 (24%) patients: 6 cardiac deaths, 16 second ACS, and 14 coronary revascularizations. Dyslipidaemia (hazard ratio [HR] 3.1 [95% confidence interval 1.5-6.6]) and diabetes mellitus (HR 4.8 [2.3-10.3]) were univariable clinical predictors of MACE. Patients with remaining obstructive non-culprit plaques (HR 3.66 [1.52-8.80]) and higher plaque burden index (HR 1.22 [1.01-1.48]) had a more risk of MACE. In multivariate analysis, with diabetes, dyslipidaemia, and plaque burden index, obstructive non-culprit plaques (HR 3.76 [1.28-11.09]) remained an independent predictor of MACE.

Conclusion: Almost a quarter of the study population experienced a new event arising from a non-culprit plaque during a follow-up of almost 5 years. ACS patients with remaining obstructive non-culprit plaques or high plaque burden have an increased risk of future MACE.
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http://dx.doi.org/10.1093/ehjci/jeu111DOI Listing
November 2014

Quantitative computed tomographic coronary angiography: does it predict functionally significant coronary stenoses?

Circ Cardiovasc Imaging 2014 Jan 26;7(1):43-51. Epub 2013 Nov 26.

Department of Radiology.

Background: Coronary lesions with a diameter narrowing ≥50% on visual computed tomographic coronary angiography (CTCA) are generally considered for referral to invasive coronary angiography. However, similar to invasive coronary angiography, visual CTCA is often inaccurate in detecting functionally significant coronary lesions. We sought to compare the diagnostic performance of quantitative CTCA with visual CTCA for the detection of functionally significant coronary lesions using fractional flow reserve (FFR) as the reference standard.

Methods And Results: CTCA and FFR measurements were obtained in 99 symptomatic patients. In total, 144 coronary lesions detected on CTCA were visually graded for stenosis severity. Quantitative CTCA measurements included lesion length, minimal area diameter, % area stenosis, minimal lumen diameter, % diameter stenosis, and plaque burden [(vessel area-lumen area)/vessel area×100]. Optimal cutoff values of CTCA-derived parameters were determined, and their diagnostic accuracy for the detection of flow-limiting coronary lesions (FFR≤0.80) was compared with visual CTCA. FFR was ≤0.80 in 54 of 144 (38%) coronary lesions. Optimal cutoff values to predict flow-limiting coronary lesion were 10 mm for lesion length, 1.8 mm2 for minimal area diameter, 73% for % area stenosis, 1.5 mm for minimal lumen diameter, 48% for % diameter stenosis, and 76% for plaque burden. No significant difference in sensitivity was found between visual CTCA and quantitative CTCA parameters (P>0.05). The specificity of visual CTCA (42%; 95% confidence interval [CI], 31%-54%) was lower than that of minimal area diameter (68%; 95% CI, 57%-77%; P=0.001), % area stenosis (76%; 95% CI, 65%-84%; P<0.001), minimal lumen diameter (67%; 95% CI, 55%-76%; P=0.001), % diameter stenosis (72%; 95% CI, 62%-80%; P<0.001), and plaque burden (63%; 95% CI, 52%-73%; P=0.004). The specificity of lesion length was comparable with that of visual CTCA.

Conclusions: Quantitative CTCA improves the prediction of functionally significant coronary lesions compared with visual CTCA assessment but remains insufficient. Functional assessment is still required in lesions of moderate stenosis to accurately detect impaired FFR.
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http://dx.doi.org/10.1161/CIRCIMAGING.112.000277DOI Listing
January 2014

Impact of iterative reconstruction on CT coronary calcium quantification.

Eur Radiol 2013 Dec 22;23(12):3246-52. Epub 2013 Sep 22.

Department of Radiology, Erasmus Medical Centre, 's-Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands,

Objectives: We evaluated the influence of sinogram-affirmed iterative reconstruction (SAFIRE) on the coronary artery calcium (CAC) score by computed tomography (CT).

Materials And Methods: Seventy patients underwent CAC imaging by 128-slice dual-source CT. CAC volume, mass and Agatston score were calculated from images reconstructed by filtered back projection (FBP) without and with incremental degrees of the SAFIRE algorithm (10-50 %). We used the repeated measuring test and the Steel-Dwass test for multiple comparisons of values and the difference ratio among different SAFIRE groups using the FBP as reference.

Results: The median Agatston score (range) decreased with incremental SAFIRE degrees: 163 (0.1 - 3,393.3), 158.4 (0.3 - 3,079.3), 137.7 (0.1 - 2,978.0), 120.6 (0 - 2,783.6), 102.6 (0 - 2,468.4) and 84.1 (0 - 2,186.9) for 0 % (FBP), 10 %, 20 %, 30 %, 40 % and 50 % SAFIRE, respectively (P < 0.05). In comparison with FBP, CAC volume (from 8.1 % to 47.7 %), CAC mass (from 5.3 % to 44.7 %) and CAC Agatston score (from 7.3 % to 48.4 %) all decreased with increasing SAFIRE from 10 % to 50 %, respectively (P < 0.05). High-grade SAFIRE resulted in the disappearance of detectable calcium in three cases with low calcium burden.

Conclusion: SAFIRE noise reduction techniques significantly affected the CAC, which potentially alters perceived cardiovascular risk.
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http://dx.doi.org/10.1007/s00330-013-3022-8DOI Listing
December 2013

Restriction of the referral of patients with stable angina for CT coronary angiography by clinical evaluation and calcium score: impact on clinical decision making.

Eur Radiol 2013 Oct 19;23(10):2676-86. Epub 2013 Jun 19.

Erasmus MC Department of Radiology, room Ca 207a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands,

Objective: To investigate the value of the calcium score (CaSc) plus clinical evaluation to restrict referral for CT coronary angiography (CTCA) by reducing the number of patients with an intermediate probability of coronary artery disease (CAD).

Methods: We retrospectively included 1,975 symptomatic stable patients who underwent clinical evaluation and CaSc calculation and CTCA or invasive coronary coronary angiography (ICA). The outcome was obstructive CAD (≥50 % diameter narrowing) assessed by ICA or CTCA in the absence of ICA. We investigated two models: (1) clinical evaluation consisting of chest pain typicality, gender, age, risk factors and ECG and (2) clinical evaluation with CaSc. Discrimination of the two models was compared. The stepwise reclassification of patients with an intermediate probability of CAD (10-90 %) after clinical evaluation followed by clinical evaluation with CaSc was assessed by clinical net reclassification improvement (NRI).

Results: Discrimination of CAD was significantly improved by adding CaSc to the clinical evaluation (AUC: 0.80 vs. 0.89, P < 0.001). CaSc and CTCA could be avoided in 9 % using model 1 and an additional 29 % of CTCAs could be avoided using model 2. Clinical NRI was 57 %.

Conclusion: CaSc plus clinical evaluation may be useful in restricting further referral for CTCA by 38 % in symptomatic stable patients with suspected CAD.

Key Points: • CT calcium scores (CaSc) could proiritise referrals for CT coronary angiography (CTCA) • CaSc provides an incremental discriminatory value of CAD compared with clinical evaluation • Risk stratification is better when clinical evaluation is combined with CaSc • Appropriate use of clinical evaluation and CaSc helps avoid unnecessary CTCA referrals.
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http://dx.doi.org/10.1007/s00330-013-2898-7DOI Listing
October 2013

Computed tomography coronary imaging as a gatekeeper for invasive coronary angiography in patients with newly diagnosed heart failure of unknown aetiology.

Eur J Heart Fail 2013 Sep 12;15(9):1028-34. Epub 2013 Jun 12.

Department of Cardiology, Thorax Centre Rotterdam, The Netherlands.

Aims: To evaluate the accuracy of cardiac computed tomography (CT) in distinguishing CAD and non-CAD heart failure (HF) and its effectiveness as a gatekeeper for invasive coronary angiography (ICA).

Methods And Results: We prospectively included 93 symptomatic patients with newly diagnosed HF of unknown aetiology (59 men; mean age 53 ± 13) and EF <45%, and/or fractional shortening <25%, and/or end-diastolic LV diameter >60 mm (men) or >55 mm (women). In all patients, the CT calcium score (CTCS) was determined. CTCS = 0 excluded CAD HF. Additional CT coronary angiography (CTCA) was performed if CTCS >0. ICA was used as the gold standard for distinguishing between CAD and non-CAD HF in patients with >20% luminal diameter narrowing on CTCA. CAD HF was defined as >50% luminal diameter narrowing in either (i) the left main coronary artery or proximal left anterior descending coronary artery or (ii) in multiple coronary arteries. Diagnostic accuracy and follow-up data (20 ± 16 months) were collected for all patients. CTCS = 0 ruled out CAD HF in 43 patients (46%). The CT algorithm had 100% sensitivity, 95% specificity, 67% positive predictive value, and 100% negative predictive value for detecting CAD HF. Patients with CTCS = 0 or non-CAD HF on CTCA had no coronary events during follow-up, and ICA could have been safely avoided in 76 out of 93 patients (82%).

Conclusion: In patients with HF of unknown aetiology, cardiac CT combining CTCS and CTCA has high accuracy for detecting CAD HF and can be used effectively as a gatekeeper for ICA.
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http://dx.doi.org/10.1093/eurjhf/hft090DOI Listing
September 2013

Additive value of semiautomated quantification of coronary artery disease using cardiac computed tomographic angiography to predict future acute coronary syndrome.

J Am Coll Cardiol 2013 Jun 3;61(22):2296-305. Epub 2013 Apr 3.

Cardiovascular Research Institute Maastricht, Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.

Objectives: The purpose of this study was to investigate whether the use of a semiautomated plaque quantification algorithm (reporting volumetric and geometric plaque properties) provides additional prognostic value for the development of acute coronary syndromes (ACS) as compared with conventional reading from cardiac computed tomography angiography (CCTA).

Background: CCTA enables the visualization of coronary plaque characteristics, of which some have been shown to predict ACS.

Methods: A total of 1,650 patients underwent 64-slice CCTA and were followed up for ACS for a mean 26 ± 10 months. In 25 patients who had ACS and 101 random controls (selected from 993 patients with coronary artery disease but without coronary event), coronary artery disease was evaluated using conventional reading (calcium score, luminal stenosis, morphology), and then independently quantified using semiautomated software (plaque volume, burden area [plaque area divided by vessel area times 100%], noncalcified percentage, attenuation, remodeling). Clinical risk profile was calculated with Framingham risk score (FRS).

Results: There were no significant differences in conventional reading parameters between controls and patients who had ACS. Semiautomated plaque quantification showed that compared to controls, ACS patients had higher total plaque volume (median: 94 mm(3) vs. 29 mm(3)) and total noncalcified volume (28 mm(3) vs. 4 mm(3), p ≤ 0.001 for both). In addition, per-plaque maximal volume (median: 56 mm(3) vs. 24 mm(3)), noncalcified percentage (62% vs. 26%), and plaque burden (57% vs. 36%) in ACS patients were significantly higher (p < 0.01 for all). A receiver-operating characteristic model predicting for ACS incorporating FRS and conventional CCTA reading had an area under the curve of 0.64; a second model also incorporating semiautomated plaque quantification had an area under the curve of 0.79 (p < 0.05).

Conclusions: The semiautomated plaque quantification algorithm identified several parameters predictive for ACS and provided incremental prognostic value over clinical risk profile and conventional CT reading. The application of this tool may improve risk stratification in patients undergoing CCTA.
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http://dx.doi.org/10.1016/j.jacc.2013.02.065DOI Listing
June 2013

Carotid plaque burden as a measure of subclinical coronary artery disease in patients with heterozygous familial hypercholesterolemia.

Am J Cardiol 2013 May 11;111(9):1305-10. Epub 2013 Feb 11.

Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.

Patients with familial hypercholesterolemia (FH) are at markedly increased risk of developing premature coronary artery disease. The objective of the present study was to evaluate the role of carotid ultrasonography as a measure of subclinical coronary artery disease in patients with FH. The present prospective study compared the presence of subclinical carotid and coronary artery disease in 67 patients with FH (mean age 55 ± 8 years, 52% men) to that in 30 controls with nonanginal chest pain (mean age 56 ± 9 years, 57% men). The carotid intima-media thickness and carotid plaque burden were assessed using B-mode ultrasonography, according to the Mannheim consensus. Coronary artery disease was assessed using computed tomographic coronary angiography. A lumen reduction >50% was considered indicative of obstructive coronary artery disease. The patients with FH and the controls had a comparable carotid intima-media thickness (0.64 vs 0.66 mm, p = 0.490), prevalence of carotid plaque (93% vs 83%, p = 0.361), and median carotid plaque score (3 vs 2, p = 0.216). Patients with FH had a significantly greater median coronary calcium score than did the controls (62 vs 5, p = 0.015). However, the prevalence of obstructive coronary artery disease was comparable (27% vs 31%, p = 0.677). No association was found between the carotid intima-media thickness and coronary artery disease. An association was found between the presence of carotid plaque and coronary artery disease in the patients with FH and the controls. The absence of carotid plaque, observed in 5 patients (7%) with FH, excluded the presence of obstructive coronary artery disease. In conclusion, the patients with FH had a high prevalence of carotid plaque and a significantly greater median coronary calcium score than did the controls. A correlation was found between carotid plaque and coronary artery disease in patients with FH; however, the presence of carotid plaque and carotid plaque burden are not reliable indicators of obstructive coronary artery disease.
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http://dx.doi.org/10.1016/j.amjcard.2013.01.274DOI Listing
May 2013

The effect of LDLR-negative genotype on CT coronary atherosclerosis in asymptomatic statin treated patients with heterozygous familial hypercholesterolemia.

Atherosclerosis 2013 Apr 8;227(2):334-41. Epub 2013 Jan 8.

Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.

Objective: To evaluate the influence of LDL receptor (LDLR) -negative mutational status on CT coronary atherosclerosis in asymptomatic statin treated patients with heterozygous familial hypercholesterolemia (FH).

Methods: Coronary CT angiography (CCTA) was performed in 145 FH patients (93 men; mean age 52 ± 8) screened for LDLR and apolipoprotein B (APOB) mutations. The extent of coronary plaque was compared between two groups: 1) 59 patients (41%) heterozygous for LDLR-negative mutations (LDLR-negative) and 2) 86 patients (59%) with reduced or normal LDLR function (LDLR-positive) consisting of 32 LDLR-defective mutations, 8 APOB mutations and 46 patients in whom no mutation could be identified. The diseased segments score (DSS) was the primary study endpoint defined as the number of coronary artery segments (0-17) with >20% luminal diameter narrowing. We compared the DSS between LDLR-negative and LDLR-positive patients. Within the LDLR-positive group a secondary analysis was performed between identified (LDLR-defective, APOB) and unidentified mutational status.

Results: The median DSS was higher in LDLR-negative than in LDLR-positive patients (4 (1-7) and 2 (0-5); P = 0.017). After adjustment for risk factors, LDLR-negative mutational status remained an independent predictor of the DSS (B = 1.09; P = 0.047). The DSS in the LDLR-positive group was similar for patients with identified and patients with unidentified mutational status.

Conclusion: In asymptomatic statin treated patients with a clinical diagnosis of FH, LDLR-negative mutational status is associated with a higher extent of subclinical CT coronary atherosclerosis.
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http://dx.doi.org/10.1016/j.atherosclerosis.2012.12.016DOI Listing
April 2013

Imaging strategies for acute chest pain in the emergency department.

AJR Am J Roentgenol 2013 Jan;200(1):W26-38

Department of Radiology, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Rotterdam, The Netherlands.

Objective: Echocardiography, radionuclide myocardial perfusion imaging (MPI), and coronary CT angiography (CTA) are the three main imaging techniques used in the emergency department for the diagnosis of acute coronary syndrome (ACS). The purpose of this article is to quantitatively examine existing evidence about the diagnostic performance of these imaging tests in this setting.

Conclusion: Our systematic search of the medical literature showed no significant difference between the modalities for the detection of ACS in the emergency department. There was a slight, positive trend favoring coronary CTA. Given the absence of large differences in diagnostic performance, practical aspects such as local practice, expertise, medical facilities, and individual patient characteristics may be more important.
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http://dx.doi.org/10.2214/AJR.11.8296DOI Listing
January 2013

Copeptin in acute chest pain: identification of acute coronary syndrome and obstructive coronary artery disease on coronary CT angiography.

Emerg Med J 2013 Nov 8;30(11):910-3. Epub 2012 Nov 8.

Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands.

Objective: To determine the diagnostic accuracy of copeptin in patients with suspected acute coronary syndrome (ACS) and its correlation with obstructive coronary artery disease (CAD) on coronary CT angiography (CTA).

Methods: Copeptin was measured at arrival in 65 consecutive patients (56 ± 10 years, 45 men) suspected of ACS and no indication for immediate invasive angiography. All patients underwent coronary CTA without disclosure of the results to the treating physician, and outcomes were classified as obstructive CAD (>50% stenosis) or no obstructive CAD (≤ 50%) in one or more vessel.

Results: The final diagnosis of ACS was established in 10 (15%) patients, 6 myocardial infarctions and 4 unstable angina pectoris. Coronary CTA detected obstructive CAD in all patients with ACS and in 10 (15%) patients with no ACS. Copeptin concentrations were higher in patients with ACS (median 7.42 pmol/l (IQR 3.71-18.72)) vs patients with no ACS (3.40 pmol/l (1.13-6.27), p=0.02). Copeptin was not higher in patients with obstructive CAD on coronary CTA (4.87 pmol/l (2.90-8.51) vs 3.60 pmol/l (1.21-6.23), p=0.20) compared with patients with no obstructive CAD.

Conclusions: Copeptin seems to be elevated in patients with ACS while there is no strong correlation with obstructive coronary disease on CTA.
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http://dx.doi.org/10.1136/emermed-2012-201596DOI Listing
November 2013

Diagnostic accuracy of 128-slice dual-source CT coronary angiography: a randomized comparison of different acquisition protocols.

Eur Radiol 2013 Mar 7;23(3):614-22. Epub 2012 Oct 7.

Department of Cardiology, Erasmus Medical Center, Room Hs 207, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

Objectives: To compare the diagnostic performance and radiation exposure of 128-slice dual-source CT coronary angiography (CTCA) protocols to detect coronary stenosis with more than 50 % lumen obstruction.

Methods: We prospectively included 459 symptomatic patients referred for CTCA. Patients were randomized between high-pitch spiral vs. narrow-window sequential CTCA protocols (heart rate below 65 bpm, group A), or between wide-window sequential vs. retrospective spiral protocols (heart rate above 65 bpm, group B). Diagnostic performance of CTCA was compared with quantitative coronary angiography in 267 patients.

Results: In group A (231 patients, 146 men, mean heart rate 58 ± 7 bpm), high-pitch spiral CTCA yielded a lower per-segment sensitivity compared to sequential CTCA (89 % vs. 97 %, P = 0.01). Specificity, PPV and NPV were comparable (95 %, 62 %, 99 % vs. 96 %, 73 %, 100 %, P > 0.05) but radiation dose was lower (1.16 ± 0.60 vs. 3.82 ± 1.65 mSv, P < 0.001). In group B (228 patients, 132 men, mean heart rate 75 ± 11 bpm), per-segment sensitivity, specificity, PPV and NPV were comparable (94 %, 95 %, 67 %, 99 % vs. 92 %, 95 %, 66 %, 99 %, P > 0.05). Radiation dose of sequential CTCA was lower compared to retrospective CTCA (6.12 ± 2.58 vs. 8.13 ± 4.52 mSv, P < 0.001). Diagnostic performance was comparable in both groups.

Conclusion: Sequential CTCA should be used in patients with regular heart rates using 128-slice dual-source CT, providing optimal diagnostic accuracy with as low as reasonably achievable (ALARA) radiation dose.
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http://dx.doi.org/10.1007/s00330-012-2663-3DOI Listing
March 2013

Coronary CT angiography outperforms calcium imaging in the triage of acute coronary syndrome.

Int J Cardiol 2013 Aug 7;167(4):1597-602. Epub 2012 May 7.

Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands.

Background: In this prospective study we determine the diagnostic value of coronary CT angiography (CTA) and calcium imaging in low to intermediate risk acute chest pain patients.

Methods: One hundred and eleven consecutive patients (57 ± 11 years, 71 males) presenting to the emergency department with chest pain suggestive of acute coronary syndrome (ACS), but without indication for immediate catheter angiography, underwent both coronary CTA and calcium imaging without disclosure of the findings to the treating physicians.

Results: ACS was diagnosed in 19 patients (17%). Coronary calcium was present in 71 patients (64%). Coronary CTA identified 74 (67%) patients with coronary plaque and 36 (32%) patients with obstructive (≥ 50%) plaque. The sensitivity and specificity of the calcium scan were: 89% and 41%. The sensitivity and specificity of coronary CTA were: 100% and 40% based on the presence of any plaque and 89% and 79% based on the presence of >50% stenosis. C-statistics of the GRACE risk score (0.77 [95% CI 0.66-0.89]) improved after addition of coronary CTA (0.93 [0.88-0.98], p<0.01), though not after addition of calcium scores (0.81 [0.71-0.91], p=0.52). Follow-up at 3 months revealed four late revascularizations (no deaths or myocardial infarctions), all of whom had obstructive CAD with calcium on CT at presentation.

Conclusions: Coronary CTA outperforms calcium imaging in the triage of patients suspected of developing ACS. Absence of plaque on coronary CTA allows safe discharge. Coronary CTA has incremental value to clinical risk scores and has the potential to reduce unnecessary hospital admissions.
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http://dx.doi.org/10.1016/j.ijcard.2012.04.099DOI Listing
August 2013

Coronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs.

Int J Cardiol 2013 Aug 19;167(4):1268-75. Epub 2012 Apr 19.

Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands.

Background: To determine the comparative effectiveness and costs of a CT-strategy and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy) for diagnosing coronary artery disease (CAD).

Methods: A decision analysis was performed based on a well-documented prospective cohort of 471 outpatients with stable chest pain with follow-up combined with best-available evidence from the literature. Outcomes were correct classification of patients as CAD- (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and indication for Revascularization (using a combination reference standard), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY). Parameter uncertainty was analyzed using probabilistic sensitivity analysis.

Results: For men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long-term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (-€229 in men, -€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was cost-saving (-€231) but also less effective compared to SOC (-0.003 QALY) in men with a pre-test probability of ≥ 70%. The CT-strategy was cost-effective in 100% of simulations, except for men with a pre-test probability ≥ 70% in which case it was 59%.

Conclusions: The results suggest that a CT-based strategy is less expensive and equally effective compared to SOC in all women and in men with a pre-test probability <70%.
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http://dx.doi.org/10.1016/j.ijcard.2012.03.151DOI Listing
August 2013
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