Publications by authors named "Edward D Nicol"

85 Publications

Prevalence and Disease Spectrum of Extracoronary Arterial Abnormalities in Spontaneous Coronary Artery Dissection.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom.

Importance: Spontaneous coronary artery dissection (SCAD) has been associated with fibromuscular dysplasia (FMD) and other extracoronary arterial abnormalities. However, the prevalence, severity, and clinical relevance of these abnormalities remain unclear.

Objective: To assess the prevalence and spectrum of FMD and other extracoronary arterial abnormalities in patients with SCAD vs controls.

Design, Setting, And Participants: This case series included 173 patients with angiographically confirmed SCAD enrolled between January 1, 2015, and December 31, 2019. Imaging of extracoronary arterial beds was performed by magnetic resonance angiography (MRA). Forty-one healthy individuals were recruited to serve as controls for blinded interpretation of MRA findings. Patients were recruited from the UK national SCAD registry, which enrolls throughout the UK by referral from the primary care physician or patient self-referral through an online portal. Participants attended the national SCAD referral center for assessment and MRA.

Exposures: Both patients with SCAD and healthy controls underwent head-to-pelvis MRA (median time between SCAD event and MRA, 1 [IQR, 1-3] year).

Main Outcome And Measures: The diagnosis of FMD, arterial dissections, and aneurysms was established according to the International FMD Consensus. Arterial tortuosity was assessed both qualitatively (presence or absence of an S curve) and quantitatively (number of curves ≥45%; tortuosity index).

Results: Of the 173 patients with SCAD, 167 were women (96.5%); mean (SD) age at diagnosis was 44.5 (7.9) years. The prevalence of FMD was 31.8% (55 patients); 16 patients (29.1% of patients with FMD) had involvement of multiple vascular beds. Thirteen patients (7.5%) had extracoronary aneurysms and 3 patients (1.7%) had dissections. The prevalence and degree of arterial tortuosity were similar in patients and controls. In 43 patients imaged with both computed tomographic angiography and MRA, the identification of clinically significant remote arteriopathies was similar. Over a median 5-year follow-up, there were 2 noncardiovascular-associated deaths and 35 recurrent myocardial infarctions, but there were no primary extracoronary vascular events.

Conclusions And Relevance: In this case series with blinded analysis of patients with SCAD, severe multivessel FMD, aneurysms, and dissections were infrequent. The findings of this study suggest that, although brain-to-pelvis imaging allows detection of remote arteriopathies that may require follow-up, extracoronary vascular events appear to be rare.
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http://dx.doi.org/10.1001/jamacardio.2021.4690DOI Listing
November 2021

Highlights of the 16th annual scientific meeting of the society of cardiovascular computed tomography.

J Cardiovasc Comput Tomogr 2021 Nov-Dec;15(6):506-512. Epub 2021 Oct 8.

Division of Cardiovascular Radiology, Mayo Clinic Rochester, MN, USA.

The 16th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting welcomed 781 digital attendees from 55 countries. The program included 27 sessions across three simultaneously streaming channels, 11 exhibitors, 153 poster presentations, and 32 ​hours of on demand videos. The main themes of the meeting included coronary artery disease, valvular heart disease, structural heart disease, and advanced analytics including machine learning. This article summaries the main themes of the meeting and some of the key presentations, which will shape the future of cardiovascular computed tomography in clinical practice.
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http://dx.doi.org/10.1016/j.jcct.2021.10.002DOI Listing
November 2021

Association of coronary artery calcium score with qualitatively and quantitatively assessed adverse plaque on coronary CT angiography in the SCOT-HEART trial.

Eur Heart J Cardiovasc Imaging 2021 Sep 16. Epub 2021 Sep 16.

BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK.

Aims: Coronary artery calcification is a marker of cardiovascular risk, but its association with qualitatively and quantitatively assessed plaque subtypes is unknown.

Methods And Results: In this post-hoc analysis, computed tomography (CT) images and 5-year clinical outcomes were assessed in SCOT-HEART trial participants. Agatston coronary artery calcium score (CACS) was measured on non-contrast CT and was stratified as zero (0 Agatston units, AU), minimal (1-9 AU), low (10-99 AU), moderate (100-399 AU), high (400-999 AU), and very high (≥1000 AU). Adverse plaques were investigated by qualitative (visual categorization of positive remodelling, low-attenuation plaque, spotty calcification, and napkin ring sign) and quantitative (calcified, non-calcified, low-attenuation, and total plaque burden; Autoplaque) assessments. Of 1769 patients, 36% had a zero, 9% minimal, 20% low, 17% moderate, 10% high, and 8% very high CACS. Amongst patients with a zero CACS, 14% had non-obstructive disease, 2% had obstructive disease, 2% had visually assessed adverse plaques, and 13% had low-attenuation plaque burden >4%. Non-calcified and low-attenuation plaque burden increased between patients with zero, minimal, and low CACS (P < 0.001), but there was no statistically significant difference between those with medium, high, and very high CACS. Myocardial infarction occurred in 41 patients, 10% of whom had zero CACS. CACS >1000 AU and low-attenuation plaque burden were the only predictors of myocardial infarction, independent of obstructive disease, and 10-year cardiovascular risk score.

Conclusion: In patients with stable chest pain, zero CACS is associated with a good but not perfect prognosis, and CACS cannot rule out obstructive coronary artery disease, non-obstructive plaque, or adverse plaque phenotypes, including low-attenuation plaque.
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http://dx.doi.org/10.1093/ehjci/jeab135DOI Listing
September 2021

Sex-Specific Computed Tomography Coronary Plaque Characterization and Risk of Myocardial Infarction.

JACC Cardiovasc Imaging 2021 09 14;14(9):1804-1814. Epub 2021 Apr 14.

Cedars-Sinai Medical Center, Los Angeles, California, USA.

Objectives: This study was designed to investigate whether coronary computed tomography angiography assessments of coronary plaque might explain differences in the prognosis of men and women presenting with chest pain.

Background: Important sex differences exist in coronary artery disease. Women presenting with chest pain have different risk factors, symptoms, prevalence of coronary artery disease and prognosis compared to men.

Methods: Within a multicenter randomized controlled trial, we explored sex differences in stenosis, adverse plaque characteristics (positive remodeling, low-attenuation plaque, spotty calcification, or napkin ring sign) and quantitative assessment of total, calcified, noncalcified and low-attenuation plaque burden.

Results: Of the 1,769 participants who underwent coronary computed tomography angiography, 772 (43%) were female. Women were more likely to have normal coronary arteries and less likely to have adverse plaque characteristics (p < 0.001 for all). They had lower total, calcified, noncalcified, and low-attenuation plaque burdens (p < 0.001 for all) and were less likely to have a low-attenuation plaque burden >4% (41% vs. 59%; p < 0.001). Over a median follow-up of 4.7 years, myocardial infarction (MI) occurred in 11 women (1.4%) and 30 men (3%). In those who had MI, women had similar total, noncalcified, and low-attenuation plaque burdens as men, but men had higher calcified plaque burden. Low-attenuation plaque burden predicted MI (hazard ratio: 1.60; 95% confidence interval: 1.10 to 2.34; p = 0.015), independent of calcium score, obstructive disease, cardiovascular risk score, and sex.

Conclusions: Women presenting with stable chest pain have less atherosclerotic plaque of all subtypes compared to men and a lower risk of subsequent MI. However, quantitative low-attenuation plaque is as strong a predictor of subsequent MI in women as in men. (Scottish Computed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590).
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http://dx.doi.org/10.1016/j.jcmg.2021.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435010PMC
September 2021

The European Association of Preventive Cardiology Aviation and Occupational Cardiology Task Force.

Eur Heart J 2021 06;42(21):2030-2033

Cardiovascular Research Laboratory, Biomedical Research Foundation, Academy of Athens, 4 Soranou Ephessiou Street, 11527 Athens, Greece.

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http://dx.doi.org/10.1093/eurheartj/ehab205DOI Listing
June 2021

Following the evidence: The pre-eminent role of coronary CT angiography in 2021.

J Cardiovasc Comput Tomogr 2021 May-Jun;15(3):285-287. Epub 2021 Mar 24.

Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA.

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http://dx.doi.org/10.1016/j.jcct.2021.03.009DOI Listing
March 2021

Multi-institution assessment of the use and risk of cardiovascular computed tomography in pediatric patients with congenital heart disease.

J Cardiovasc Comput Tomogr 2021 Sep-Oct;15(5):441-448. Epub 2021 Jan 27.

Minneapolis Heart Institute and Foundation, Minneapolis, MN, USA; Children's Minnesota, Minneapolis, MN, USA. Electronic address:

Background: Cardiac computed tomography (CT) is increasingly used in pediatric patients with congenital heart disease (CHD). Variability of practice and of comprehensive diagnostic risk across institutions is not known.

Methods: Four centers prospectively enrolled consecutive pediatric CHD patients <18 years of age undergoing cardiac CT from January 6, 2017 to 1/30/2020. Patient characteristics, cardiac CT data and comprehensive diagnostic risk were compared by age and institutions. Risk categories included sedation and anesthesia use, vascular access, contrast exposure, cardiovascular medication, adverse events (AEs), and estimated radiation dose.

Results: Cardiac CT was performed in 1045 pediatric patients at a median (interquartile range, IQR) age of 1.7 years (0.3, 11.0). The most common indications were arterial abnormalities, suspected coronary artery anomalies, functionally single ventricle heart disease, and tetralogy of Fallot/pulmonary atresia. Sedation was used in 8% and anesthesia in 11% of patients. Peripheral vascular access was utilized for 93%. Median contrast volume was 2 ​ml/kg. Beta blockers were administered in 11% of cases and nitroglycerin in 2% of cases. The median (IQR) total procedural dose length product (DLP) was 20 ​mGy∗cm (10, 50). Sedation, vascular access, contrast exposure, use of cardiovascular medications and radiation dose estimates varied significantly by institution and age (p ​< ​0.001). Seven minor adverse events (0.7%) and no major adverse events were reported.

Conclusion: Cardiac CT for CHD is safe in pediatric patients when appropriate CT technology and expertise are available. Scans can be acquired at relatively low radiation exposure with few minor adverse events.
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http://dx.doi.org/10.1016/j.jcct.2021.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313631PMC
January 2021

Prevalence of Thrombotic Complications in ICU-Treated Patients With Coronavirus Disease 2019 Detected With Systematic CT Scanning.

Crit Care Med 2021 05;49(5):804-815

Royal Brompton Hospital, London, United Kingdom.

Objectives: Severe coronavirus disease 2019 is associated with an extensive pneumonitis and frequent coagulopathy. We sought the true prevalence of thrombotic complications in critically ill patients with severe coronavirus disease 2019 on the ICU, with or without extracorporeal membrane oxygenation.

Design: We undertook a single-center, retrospective analysis of 72 critically ill patients with coronavirus disease 2019-associated acute respiratory distress syndrome admitted to ICU. CT angiography of the thorax, abdomen, and pelvis were performed at admission as per routine institution protocols, with further imaging as clinically indicated. The prevalence of thrombotic complications and the relationship with coagulation parameters, other biomarkers, and survival were evaluated.

Setting: Coronavirus disease 2019 ICUs at a specialist cardiorespiratory center.

Patients: Seventy-two consecutive patients with coronavirus disease 2019 admitted to ICU during the study period (March 19, 2020, to June 23, 2020).

Interventions: None.

Measurements And Main Results: All but one patient received thromboprophylaxis or therapeutic anticoagulation. Among 72 patients (male:female = 74%; mean age: 52 ± 10; 35 on extracorporeal membrane oxygenation), there were 54 thrombotic complications in 42 patients (58%), comprising 34 pulmonary arterial (47%), 15 peripheral venous (21%), and five (7%) systemic arterial thromboses/end-organ embolic complications. In those with pulmonary arterial thromboses, 93% were identified incidentally on first screening CT with only 7% suspected clinically. Biomarkers of coagulation (e.g., d-dimer, fibrinogen level, and activated partial thromboplastin time) or inflammation (WBC count, C-reactive protein) did not discriminate between patients with or without thrombotic complications. Fifty-one patients (76%) survived to discharge; 17 (24%) patients died. Mortality was significantly greater in patients with detectable thrombus (33% vs 10%; p = 0.022).

Conclusions: There is a high prevalence of thrombotic complications, mainly pulmonary, among coronavirus disease 2019 patients admitted to ICU, despite anticoagulation. Detection of thrombus was usually incidental, not predicted by coagulation or inflammatory biomarkers, and associated with increased risk of death. Systematic CT imaging at admission should be considered in all coronavirus disease 2019 patients requiring ICU.
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http://dx.doi.org/10.1097/CCM.0000000000004890DOI Listing
May 2021

Prevalence and clinical implications of valvular calcification on coronary computed tomography angiography.

Eur Heart J Cardiovasc Imaging 2021 02;22(3):262-270

University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Chancellor's Building, 49 Little France Crescent, Edinburgh EH164SB, UK.

Aims: Valvular heart disease can be identified by calcification on coronary computed tomography angiography (CCTA) and has been associated with adverse clinical outcomes. We assessed aortic and mitral valve calcification in patients presenting with stable chest pain and their association with cardiovascular risk factors, coronary artery disease, and cardiovascular outcomes.

Methods And Results: In 1769 patients (58 ± 9 years, 56% male) undergoing CCTA for stable chest pain, aortic and mitral valve calcification were quantified using Agatston score. Aortic valve calcification was present in 241 (14%) and mitral calcification in 64 (4%). Independent predictors of aortic valve calcification were age, male sex, hypertension, diabetes mellitus, and cerebrovascular disease, whereas the only predictor of mitral valve calcification was age. Patients with aortic and mitral valve calcification had higher coronary artery calcium scores and more obstructive coronary artery disease. The composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, or non-fatal stroke was higher in those with aortic [hazard ratio (HR) 2.87; 95% confidence interval (CI) 1.60-5.17; P < 0.001] or mitral (HR 3.50; 95% CI 1.47-8.07; P = 0.004) valve calcification, but this was not independent of coronary artery calcification or obstructive coronary artery disease.

Conclusion: Aortic and mitral valve calcification occurs in one in six patients with stable chest pain undergoing CCTA and is associated with concomitant coronary atherosclerosis. Whilst valvular calcification is associated with a higher risk of cardiovascular events, this was not independent of the burden of coronary artery disease.
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http://dx.doi.org/10.1093/ehjci/jeaa263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899264PMC
February 2021

Are conflict of interest declarations appropriate to allow sufficient consideration of potential bias in presentations?

Future Healthc J 2020 Oct;7(3):226-229

Royal Brompton Hospital, London, UK and honorary senior lecturer, National Heart and Lung Institute, London, UK.

Background: Potential conflicts of interest (CoI) are common in medical research, necessitating the use of CoI declarations. There is currently no consensus document or external authority guiding CoI declarations in conference settings, resulting in declarations of variable quality and utility.

Methods: We explored four CoI declaration parameters (sufficient slide display time; the presence of any verbal explanation pertaining to relevant CoI; the use of an adequate font size; and whether the nature and relevance of the CoI was described). Parameters were graded from one to three points, with the sum of parameters providing an overall declaration quality out of 12. We then applied this scoring system to recordings of presentations from the British Cardiovascular Society (BCS) annual conference 2018 which were available online.

Results: Sixty-nine presentations were suitable for inclusion, of which 47 (68%) contained a CoI statement. Thirty-six of the 47 (77%) presentations declared that they had no CoI. In the remaining 11 (23%) with reported CoI, the median time spent displaying CoI was 1 second (interquartile range (IQR) 0.7-3.3). The median quality score for presentations was 7 (IQR 6-10).

Conclusion: This study demonstrates utility in considering aspects of CoI declarations at conferences to improve transparency.
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http://dx.doi.org/10.7861/fhj.2020-0018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571736PMC
October 2020

Using FFR to Guide Management Strategy in Women: Two Steps Forward and One Step Back.

JACC Cardiovasc Imaging 2020 12 26;13(12):2588-2590. Epub 2020 Aug 26.

University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom; Royal Papworth Hospital, Cambridge, United Kingdom.

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http://dx.doi.org/10.1016/j.jcmg.2020.07.019DOI Listing
December 2020

Opportunities and challenges of implementing computed tomography fractional flow reserve into clinical practice.

Heart 2020 09 19;106(18):1387-1393. Epub 2020 Jun 19.

Departments of Cardiology and Radiology, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK

CT-derived fractional flow reserve (CT-FFR) uses computational fluid dynamics to derive non-invasive FFR to determine the haemodynamic significance of coronary artery lesions. Studies have demonstrated good diagnostic accuracy of CT-FFR and reassuring short-term clinical outcome data.As a prerequisite, high-quality CT coronary angiography (CTCA) images are required with good heart rate control and pre-treatment with glyceryl trinitrate, which would otherwise render CTCA as unsuitable for CT-FFR. CT-FFR can determine the functional significance of CAD lesions, and there are supportive data for its use in clinical decision-making. However, the downstream impact on myocardial ischaemic burden or viability cannot be obtained.Several challenges remain with implementation of CT-FFR, including interpretation, training, availability, resource utilisation and funding. Further research is required to determine which cases should be considered for clinical CT-FFR analysis, with additional practical guidance on how to implement this emerging technique in clinical practice. Furthermore, long-term prognostic data are required before widespread clinical implementation of CT-FFR can be recommended.While there are several potential opportunities for CT-FFR, at present there remain important systemic and technical limitations and challenges that need to be overcome prior to routine integration of CT-FFR into clinical practice.
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http://dx.doi.org/10.1136/heartjnl-2019-315607DOI Listing
September 2020

CT imaging prior to transcatheter aortic valve implantation in the UK.

Open Heart 2020 6;7(1):e001233. Epub 2020 Apr 6.

University of Edinburgh Centre for Cardiovascular Sciences, Edinburgh, UK.

Objective: This cross-sectional observational study sought to describe variations in CT in the context of transcatheter aortic valve implantation (CT-TAVI) as currently performed in the UK.

Methods: 408 members of the British Society of Cardiovascular Imaging were invited to complete a 27-item online CT-TAVI survey.

Results: 47 responses (12% response rate) were received from 40 cardiac centres, 23 (58%) of which performed TAVI on-site (TAVI centres). Only six respondents (13%) performed high-volume activity (>200 scans per year) compared with 13 (28%) performing moderate (100-200 scans per year) and 27 (59%) performing low (0-99 scans per year) volume activity. Acquisition protocols varied (41% retrospective, 12% prospective with wide padding, 47% prospective with narrow padding), as did the phase of reporting (45% systolic, 37% diastolic, 11% both, 6% unreported). Median dose length product was 675 mGy.cm (IQR 477-954 mGy.cm). Compared with non-TAVI centres, TAVI centres were more likely to report minimum iliofemoral luminal diameter (n=25, 96% vs n=7, 58%, p=0.003) and optimal tube angulation for intervention (n=12, 46% vs n=1, 8%, p=0.02).

Conclusions: This national survey formally describes current CT-TAVI practice in the UK. High-volume activity was only present at one in seven cardiac CT centres. There is wide variation in scan acquisition, scan reporting and radiation dose exposure in cardiac CT centres.
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http://dx.doi.org/10.1136/openhrt-2019-001233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254150PMC
December 2020

Low-Attenuation Noncalcified Plaque on Coronary Computed Tomography Angiography Predicts Myocardial Infarction: Results From the Multicenter SCOT-HEART Trial (Scottish Computed Tomography of the HEART).

Circulation 2020 05 16;141(18):1452-1462. Epub 2020 Mar 16.

Cedars-Sinai Medical Centre, Los Angeles, CA (P.M., S.C., P.J.S., D.S.B., D.D.).

Background: The future risk of myocardial infarction is commonly assessed using cardiovascular risk scores, coronary artery calcium score, or coronary artery stenosis severity. We assessed whether noncalcified low-attenuation plaque burden on coronary CT angiography (CCTA) might be a better predictor of the future risk of myocardial infarction.

Methods: In a post hoc analysis of a multicenter randomized controlled trial of CCTA in patients with stable chest pain, we investigated the association between the future risk of fatal or nonfatal myocardial infarction and low-attenuation plaque burden (% plaque to vessel volume), cardiovascular risk score, coronary artery calcium score or obstructive coronary artery stenoses.

Results: In 1769 patients (56% male; 58±10 years) followed up for a median 4.7 (interquartile interval, 4.0-5.7) years, low-attenuation plaque burden correlated weakly with cardiovascular risk score (=0.34; <0.001), strongly with coronary artery calcium score (=0.62; <0.001), and very strongly with the severity of luminal coronary stenosis (area stenosis, =0.83; <0.001). Low-attenuation plaque burden (7.5% [4.8-9.2] versus 4.1% [0-6.8]; <0.001), coronary artery calcium score (336 [62-1064] versus 19 [0-217] Agatston units; <0.001), and the presence of obstructive coronary artery disease (54% versus 25%; <0.001) were all higher in the 41 patients who had fatal or nonfatal myocardial infarction. Low-attenuation plaque burden was the strongest predictor of myocardial infarction (adjusted hazard ratio, 1.60 (95% CI, 1.10-2.34) per doubling; =0.014), irrespective of cardiovascular risk score, coronary artery calcium score, or coronary artery area stenosis. Patients with low-attenuation plaque burden greater than 4% were nearly 5 times more likely to have subsequent myocardial infarction (hazard ratio, 4.65; 95% CI, 2.06-10.5; <0.001).

Conclusions: In patients presenting with stable chest pain, low-attenuation plaque burden is the strongest predictor of fatal or nonfatal myocardial infarction. These findings challenge the current perception of the supremacy of current classical risk predictors for myocardial infarction, including stenosis severity. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01149590.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.044720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195857PMC
May 2020

Occupational Cardiology: The need for a 21st century sub-specialty?

Eur Heart J 2019 12;40(48):3878-3881

Consultant Cardiologist Oxford Heart Centre John Radcliffe Hospital Oxford, UK.

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http://dx.doi.org/10.1093/eurheartj/ehz844DOI Listing
December 2019

Clinical occupational assessment pre- and post-cardiac surgery.

Eur Heart J 2019 Oct;40(40):3283-3286

Consultant Cardiologist Dept. of Cardiology, John Radcliffe Hospital, Oxford, UK.

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http://dx.doi.org/10.1093/eurheartj/ehz700DOI Listing
October 2019

The importance of exercise testing in occupational cardiovascular assessment for high-hazard professions.

Eur Heart J 2019 Oct;40(37):3078-3080

Consultant Cardiologist, Aviation Medicine Clinical Service, Centre of Aviation Medicine, RAF Henlow, Beds., UK.

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http://dx.doi.org/10.1093/eurheartj/ehz664DOI Listing
October 2019

Assessment of clinical and occupational cardiovascular risk.

Eur Heart J 2019 08;40(29):2392-2395

FACC DAvMed Consultant Cardiologist Aviation Medicine Clinical Service Centre of Aviation Medicine RAF Henlow Beds., UK.

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http://dx.doi.org/10.1093/eurheartj/ehz513DOI Listing
August 2019

An Introduction to Occupational Cardiology.

Eur Heart J 2019 08;40(29):2389-2392

Consultant Cardiologist Aviation Medicine Clinical Service Centre of Aviation Medicine RAF Henlow Beds., SG16 6DN, UK.

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http://dx.doi.org/10.1093/eurheartj/ehz512DOI Listing
August 2019

Occupational coronary artery disease assessment: moving beyond the stenosis paradigm.

Eur Heart J 2019 09;40(34):2844-2846

Lieutenant Colonel, United States Air Force, Chief of Cardiology USAF Aeromedical Consult Service, Surgeon General Aerospace Cardiology Consultant (USAF), Federal Air Surgeon Cardiology Consultant (FAA), United States Air Force School of Aerospace Medicine, Wright Patterson Air Force Base, OH, USA.

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http://dx.doi.org/10.1093/eurheartj/ehz625DOI Listing
September 2019

The role of advanced cardiac imaging in occupational cardiology.

Eur Heart J 2019 Sep;40(35):2934-2937

Consultant Cardiologist, Oxford University Hospitals NHS Foundation Trust, Dept. of Cardiology, John Radcliffe Hospital, Oxford, UK.

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http://dx.doi.org/10.1093/eurheartj/ehz638DOI Listing
September 2019

The assessment of asymptomatic inherited QT prolongation for high-hazard occupations.

Eur Heart J 2019 09;40(33):2750-2753

Consultant Cardiologist, Aviation Medicine Clinical Service, Centre of Aviation Medicine, RAF Henlow, Beds., UK.

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http://dx.doi.org/10.1093/eurheartj/ehz579DOI Listing
September 2019

ECG interpretation.

Eur Heart J 2019 08;40(32):2663-2666

Consultant Cardiologist Aviation Medicine Clinical Service Centre of Aviation Medicine RAF Henlow Beds., SG16 6DN, UK.

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http://dx.doi.org/10.1093/eurheartj/ehz559DOI Listing
August 2019

Electrophysiologic assessment of aircrew and other high-hazard employees.

Eur Heart J 2019 Aug;40(31):2560-2563

Consultant Cardiologist, Aviation Medicine Clinical Service, Centre of Aviation Medicine, RAF Henlow, Beds., UK.

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http://dx.doi.org/10.1093/eurheartj/ehz558DOI Listing
August 2019

Standardized reporting systems for computed tomography coronary angiography and calcium scoring: A real-world validation of CAD-RADS and CAC-DRS in patients with stable chest pain.

J Cardiovasc Comput Tomogr 2020 Jan - Feb;14(1):3-11. Epub 2019 Jul 26.

Glasgow Clinical Research Imaging Facility, Queen Elizabeth University Hospital, Glasgow, Scotland, UK; Glasgow University, Glasgow, Scotland, UK.

Objectives: To assess the prognostic implications of standardized reporting systems for coronary computed tomography angiography (CCTA) and coronary artery calcium scores (CACS) in patients with stable chest pain.

Background: The Coronary Artery Disease Reporting And Data System (CAD-RADS) and Coronary Artery Calcium - Data and Reporting System (CAC-DRS) aim to improve communication of CACS and CCTA results, but its influence on prognostication is unknown.

Methods: Images from 1769 patients who underwent CCTA as part of the Scottish Computed Tomography of the HEART (SCOT-HEART) multi-center randomized controlled trial were assessed. CACS were classified as CAC-DRS 0 to 3 based on Agatston scores. CCTA were classified as CAD-RADS 0 to 5 based on the most clinically relevant finding per patient. The primary outcome was the five-year events of fatal and non-fatal myocardial infarction.

Results: Patients had a mean age of 58 ± 10 years and 56% were male. CAC-DRS 0, 1, 2 and 3 occurred in 642 (36%), 510 (29%), 239 (14%) and 379 (21%) patients respectively. CAD-RADS 0, 1, 2, 3, 4A, 4B and 5 occurred in 622 (35%), 327 (18%), 211 (12%), 165 (9%), 221 (12%), 42 (2%) and 181 (10%) patients respectively. Patients classified as CAC-DRS 3 were at an increased risk of fatal or non-fatal myocardial infarction compared to CAC-DRS 0 patients (hazard ratio (HR) 9.41; 95% confidence interval (CI) 3.24, 27.31; p < 0.001). Patients with higher CAD-RADS categories were at an increased risk of fatal or non-fatal myocardial infarction, with patients classified as CAD-RADS 4B at the highest risk compared to CAD-RADS 0 patients (HR 19.14; 95% CI 4.28, 85.53; p < 0.001).

Conclusion: Patients with higher CAC-DRS and CAD-RADS scores were at increased risk of subsequent fatal and non-fatal myocardial infarction. This confirms that the classification provides additional prognostic discrimination for future coronary heart disease events.
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http://dx.doi.org/10.1016/j.jcct.2019.07.010DOI Listing
July 2020

Cardiac MRI improves cardiovascular risk stratification in hazardous occupations.

J Cardiovasc Magn Reson 2019 07 29;21(1):48. Epub 2019 Jul 29.

Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, England.

Background: The benefit of cardiovascular magnetic resonance Imaging (CMR) in assessing occupational risk is unknown. Pilots undergo frequent medical assessment for occult disease, which threatens incapacitation or distraction during flight. ECG and examination anomalies often lead to lengthy restriction, pending full investigation. CMR provides a sensitive, specific assessment of cardiac anatomy, tissue characterisation, perfusion defects and myocardial viability. We sought to determine if CMR, when added to standard care, would alter occupational outcome.

Methods: A retrospective review was conducted of all personnel attending the RAF Aviation Medicine Consultation Service (AMCS) for assessment of a cardiac anomaly, over a 2-year period. Those undergoing standard of care (history, examination, exercise ECG, 24 h-Holter and transthoracic echocardiography), and those undergoing a CMR in addition, were identified. The influence of CMR upon the final decision regarding flying restriction was determined by comparing the diagnosis reached with standard of care plus CMR vs. standard of care alone.

Results: Of the ~ 8000 UK military aircrew, 558 personnel were seen for cardiovascular assessment. Fifty-two underwent CMR. A normal TTE did not reliably exclude abnormalities subsequently detected by CMR. Addition of CMR resulted in an upgraded occupational status in 62% of those investigated, with 37% returning to unrestricted duties. Only 8% of referrals were undiagnosed following CMR. All these were cases of borderline chamber dilatation and reduction in systolic function in whom diagnostic uncertainty remained between physiological exercise adaptation and early cardiomyopathy.

Conclusions: CMR increases the likelihood of a definitive diagnosis and of return to flying. This study supports early use of CMR in occupational assessment for high-hazard occupations.
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http://dx.doi.org/10.1186/s12968-019-0544-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661777PMC
July 2019

The Future of Cardiovascular Computed Tomography: Advanced Analytics and Clinical Insights.

JACC Cardiovasc Imaging 2019 06;12(6):1058-1072

Department of Radiology and Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Cardiovascular computed tomography (CCT) has undergone rapid maturation over the last decade and is now of proven clinical utility in the diagnosis and management of coronary artery disease, in guiding structural heart disease intervention, and in the diagnosis and treatment of congenital heart disease. The next decade will undoubtedly witness further advances in hardware and advanced analytics that will potentially see an increasingly core role for CCT at the center of clinical cardiovascular practice. In coronary artery disease assessment this may be via improved hemodynamic adjudication, and shear stress analysis using computational flow dynamics, more accurate and robust plaque characterization with spectral or photon-counting CT, or advanced quantification of CT data via artificial intelligence, machine learning, and radiomics. In structural heart disease, CCT is already pivotal to procedural planning with adjudication of gradients before and following intervention, whereas in congenital heart disease CCT is already used to support clinical decision making from neonates to adults, often with minimal radiation dose. In both these areas the role of computational flow dynamics, advanced tissue printing, and image modelling has the potential to revolutionize the way these complex conditions are managed, and CCT is likely to become an increasingly critical enabler across the whole advancing field of cardiovascular medicine.
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http://dx.doi.org/10.1016/j.jcmg.2018.11.037DOI Listing
June 2019
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