scholarly journals Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease

2019 ◽  
Vol 20 (11) ◽  
pp. 1198-1207 ◽  
Author(s):  
Luis Eduardo Juarez-Orozco ◽  
Antti Saraste ◽  
Davide Capodanno ◽  
Eva Prescott ◽  
Haitham Ballo ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
False Positive ◽  
Diagnostic Technique ◽  
Non Invasive ◽  
Selection Tool ◽  
Post Test ◽  
Artery Disease ◽  
Post Test Probability ◽  
Test Probability

Abstract Aims To provide a pooled estimation of contemporary pre-test probabilities (PTPs) of significant coronary artery disease (CAD) across clinical patient categories, re-evaluate the utility of the application of diagnostic techniques according to such estimates, and propose a comprehensive diagnostic technique selection tool for suspected CAD. Methods and results Estimates of significant CAD prevalence across sex, age, and type of chest pain categories from three large-scale studies were pooled (n = 15 815). The updated PTPs and diagnostic performance profiles of exercise electrocardiogram, invasive coronary angiography, coronary computed tomography angiography (CCTA), positron emission tomography (PET), stress cardiac magnetic resonance (CMR), and SPECT were integrated to define the PTP ranges in which ruling-out CAD is possible with a post-test probability of <10% and <5%. These ranges were then integrated in a new colour-coded tabular diagnostic technique selection tool. The Bayesian relationship between PTP and the rate of diagnostic false positives was explored to complement the characterization of their utility. Pooled CAD prevalence was 14.9% (range = 1–52), clearly lower than that used in current clinical guidelines. Ruling-out capabilities of non-invasive imaging were good overall. The greatest ruling-out capacity (i.e. post-test probability <5%) was documented by CCTA, PET, and stress CMR. With decreasing PTP, the fraction of false positive findings rapidly increased, although a lower CAD prevalence partially cancels out such effect. Conclusion The contemporary PTP of significant CAD across symptomatic patient categories is substantially lower than currently assumed. With a low prevalence of the disease, non-invasive testing can rarely rule-in the disease and focus should shift to ruling-out obstructive CAD. The large proportion of false positive findings must be taken into account when patients with low PTP are investigated.

Stress echocardiography vs coronary oomputed tomography angiography for the detection of obstructive coronary artery disease in patients aged >70 years with suspected stable coronary artery disease

2020 ◽  
Vol 19 (5) ◽  
pp. 2374
Author(s):  
S. G. Kozlov ◽  
O. V. Chernova ◽  
V. N. Shitov ◽  
T. N. Veselova ◽  
M. A. Saidova ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Positive Result ◽  
Stress Echocardiography ◽  
Stable Coronary Artery Disease ◽  
Diagnostic Value ◽  
Anginal Pain ◽  
Post Test ◽  
Artery Disease ◽  
Test Probability

Aim. To compare stress echocardiography and coronary computed tomography angiography (CCTA) in the diagnosis of stable coronary artery disease (CAD) in patients aged >70 years.Materials and methods. The study included 390 patients aged >70 years with suspected stable CAD, which underwent elective coronary artery angiography (CAG). Initially, patients for whom stress echocardiography and CCTA is appropriate was determined. After that diagnostic accuracy of both methods in the detection of obstructive CAD was evaluated in patients with atypical angina and non-anginal chest pain.Results. Among 111 patients with atypical angina and non-anginal pain which underwent stress echocardiography and had unequivocal results, 69 (62 %) patients had obstructive CAD. Stress echocardiography has sensitivity of 89%, specificity of 95%, positive likelihood ratio (LR+) of 17,8, and negative likelihood ratio (LR-) of 0,1. Positive result increased probability of obstructive CAD from 62% to 95%, while negative result reduced probability to 16%. Among 82 patients with atypical angina and non-anginal pain which underwent CCTA, 48 (59 %) patients had obstructive CAD. CCTA has sensitivity of 100 %, specificity of 88%, LR+ of 8,3, and LR- of 0,3. Positive result increased post-test probability of obstructive CAD from 59% to 86%, while negative result reduced post-test probability to 0%.Conclusion. Stress echocardiography and CCTA has comparable diagnostic accuracy in the detection of obstructive CAD in patients aged >70 years with atypical angina and non-anginal pain. Stress echocardiography has a greater diagnostic value of positive result; CCTA has a greater diagnostic value of negative result.

scholarly journals The Diagnostic Accuracy of Сoronary Сomputed Tomography Angiography in the Diagnosis of Stable Coronary Artery Disease in Patients Aged 70 Years and Older

Kardiologiia ◽  
2019 ◽  
Vol 59 (12) ◽  
pp. 28-34
Author(s):  
S. G. Kozlov ◽  
O. V. Chernova ◽  
T. N. Veselova ◽  
S. K. Ternovoy
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Diagnostic Accuracy ◽  
Positive Result ◽  
Likelihood Ratio ◽  
Stable Coronary Artery Disease ◽  
Post Test ◽  
Artery Disease ◽  
Post Test Probability ◽  
Test Probability

Aim: The purpose of this study was to evaluate the diagnostic accuracy of сoronary сomputed tomography angiography (CCTA) in the diagnosis of stable coronary artery disease (CAD) in patients aged ≥70 years. Materials and methods: The study included 390 patients aged ≥70 years with symptoms suggested stable CAD which underwent elective coronary artery angiography (CAG). Initially the prevalence of angiographically significant CAD was estimated according to the gender and chest pain character, and identifications of patients in whom CCTA was appropriate. After that diagnostic accuracy and сost-efficiency of CCTA in the diagnosis of stable CAD in 82 patients with atypical angina and non-anginal chest pain were evaluated. Results: The prevalence of obstructive CAD in patients with typical angina was very high and they were excluded from the final analysis. Among 82 patients with atypical angina and non-anginal pain which underwent CCTA 48 (59%) patients had obstructive CAD. CСTA data matched with results of CAG in all cases. Among 34 patients that had non-obstructive CAD the results of CCTA and CAG matched in 88% cases. CCTA has sensitivity, specificity, positive predictive value, negative predictive value of 100%, 88%, 92% and 100% respectively. The likelihood ratio for positive result was 8.3, likelihood ratio for negative result was 0.3. Positive result increased post-test probability of obstructive CAD from 42% to 86%, negative result reduced post-test probability of obstructive CAD to 0%. Conclusion: negative CCTA result in patients aged 70 years and older with atypical angina and non-anginal pain allows to exclude the presence of obstructive CAD.  The likelihood ratio for positive result indicates a moderately difference between the pre-test and post-test probability of the presence of obstructive CAD. In patients aged ≥70 years with atypical angina or non-anginal chest pain which have inconclusive results of functional testing or unable undergo functional testing CCTA allows to increase diagnostic yield of CAG and reduce the frequency of minor complications and diagnostic evaluation costs.

Stress-induced Myocardial Ischaemia – Perfusion Contrast Echocardiography to Evaluate Presence and Severity of Coronary Artery Disease

2011 ◽  
Vol 7 (3) ◽  
pp. 172
Author(s):  
Benoy Nalin Shah ◽  
Roxy Senior ◽  
◽  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Myocardial Perfusion ◽  
Contrast Echocardiography ◽  
Evidence Base ◽  
Suspected Coronary Artery Disease ◽  
Ultrasound Contrast Agents ◽  
Prognostic Information ◽  
Non Invasive ◽  
Artery Disease

The development of stable transpulmonary ultrasound contrast agents (UCAs) has allowed the echocardiographic assessment of myocardial perfusion, a technique known as myocardial contrast echocardiography (MCE). MCE exploits the ultrasonic properties of UCAs, which consist of acoustically active gas-filled microspheres. These are intravascular agents that have a rheology similar to red blood cells and thus allow analysis of myocardial blood flow both at rest and after stress. The combined assessment of wall motion and myocardial perfusion provides significant diagnostic and prognostic information during stress echocardiography. Functional imaging tests, such as myocardial perfusion scintigraphy and stress cardiac magnetic resonance imaging, are also used for non-invasive assessment of coronary disease. The principal advantages of MCE are that it does not expose the patient to ionising radiation or radioactive pharmaceuticals, is not contraindicated in patients with an implanted metallic device or who suffer from claustrophobia and it can be performed at the bedside. The purpose of this article is to outline the physiological principles underpinning ischaemia testing with MCE before proceeding to review the evidence base for MCE in patients with known or suspected coronary artery disease.

scholarly journals Screening for coronary artery disease in early surgical treatment of acute aortic valve infective endocarditis

2020 ◽  
Author(s):  
Wiebe G Knol ◽  
Ali R Wahadat ◽  
Jolien W Roos-Hesselink ◽  
Nicolas M Van Mieghem ◽  
Wilco Tanis ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Infective Endocarditis ◽  
Perioperative Complications ◽  
Invasive Coronary Angiography ◽  
Perioperative Myocardial Infarction ◽  
Non Invasive ◽  
Estimated Risk ◽  
Artery Disease

Abstract OBJECTIVES In patients with unknown coronary status undergoing surgery for acute infective endocarditis (IE), the need to screen for coronary artery disease (CAD) and the risk of embolization during invasive coronary angiography (ICA) are debated. Coronary computed tomography angiography (CCTA) is a non-invasive alternative in these patients. We aimed to evaluate the safety and feasibility of ICA and CCTA to diagnose CAD, and the necessity to treat CAD to prevent CAD-related postoperative complications. METHODS In this single-centre retrospective cohort study, all patients with acute aortic IE between 2009 and 2019 undergoing surgery were selected. Outcomes were any clinically evident embolization after preoperative ICA, in-hospital mortality, perioperative myocardial infarction or unplanned revascularization and postoperative renal function. RESULTS Of the 159 included patients, CAD status was already known in 14. No preoperative diagnostics for CAD was done in 46/145, a CCTA was performed in 54/145 patients and an ICA in 52/145 patients. Significant CAD was found after CCTA in 22% and after ICA in 21% of patients. In 1 of the 52 (2%) patients undergoing preoperative ICA, a cerebral embolism occurred. The rate of perioperative myocardial infarction or unplanned revascularization in patients not screened for CAD was 2% (1 out of 46 patients). CONCLUSIONS Although the risk of embolism after preoperative ICA is low, it should be carefully weighed against the estimated risk of CAD-related perioperative complications. CCTA can serve as a gatekeeper for ICA in most patients with acute aortic IE.

scholarly journals Diagnostic and prognostic value of coronary artery calcium score of zero: is it time for guidelines to change?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
E Arbas Redondo ◽  
D Tebar Marquez ◽  
I.D Poveda Pinedo ◽  
R Dalmau Gonzalez-Gallarza ◽  
S.C Valbuena Lopez ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Coronary Artery Calcium ◽  
Cardiac Ct ◽  
Invasive Coronary Angiography ◽  
Agatston Score ◽  
Non Invasive ◽  
Artery Disease

Abstract Introduction Cardiac computed tomography (CT) use has progressively increased as the preferred initial test to rule out coronary artery disease (CAD) when clinical likelihood is low. Coronary artery calcium (CAC) detected by CT is a well-established marker for cardiovascular risk. However, it is not recommended for diagnosis of obstructive CAD. Absence of CAC, defined as an Agatston score of zero, has been associated to good prognosis despite underestimation of non-calcified plaques. Purpose To evaluate whether zero CAC score could help ruling out obstructive CAD in a safely manner. Methods Observational study based on a prospective database of patients (pts) referred to cardiac CT between 2017 and 2019. Pts with an Agatston score of zero were selected. Results We included 176 pts with zero CAC score and non-invasive coronary angiography performed. The median duration of follow-up was 23.9 months. Baseline characteristics of the population are shown in Table 1. In 117 pts (66.5%), cardiac CT was indicated as part of their chest pain evaluation. Mean age was 57.2 years old, 68.2% were women and only and 9.4% were active smokers. Normal coronary arteries were found in 173 pts (98.3%). Obstructive CAD, defined as ≥50% luminal diameter stenosis of a major vessel, was present in 1/176 (0.6%); while non-obstructive atherosclerotic plaques were found in 2 pts (1.1%). During follow-up, one patient died of out-of-hospital cardiac arrest. None either suffered from myocardial infarction or needed coronary revascularization. Conclusions In our cohort, a zero CAC score detected by cardiac CT rules out obstructive coronary artery disease in 98.3%, with only 1.7% of non-calcified atherosclerosis plaques and 0.6% of major adverse events. Although further research on this topic is needed, these results support the fact that non-invasive coronary angiography could be avoided in patients with low clinical likelihood of CAD and zero CAC score, facilitating the management of the increasing demand for coronary CT and reduction of radiation dose. Funding Acknowledgement Type of funding source: None

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