scholarly journals Management of established coronary artery disease in aircrew without myocardial infarction or revascularisation

Heart ◽  
2018 ◽  
Vol 105 (Suppl 1) ◽  
pp. s25-s30 ◽  
Author(s):  
Eddie D Davenport ◽  
Gary Gray ◽  
Rienk Rienks ◽  
Dennis Bron ◽  
Thomas Syburra ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Expert Consensus ◽  
Cardiac Risk Factor ◽  
Fractional Flow ◽  
Established Coronary Artery Disease ◽  
Flow Reserve ◽  
Artery Disease

This paper is part of a series of expert consensus documents covering all aspects of aviation cardiology. In this manuscript, we focus on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease in those without myocardial infarction or revascularisation (both pilots and non-pilot aviation professionals). We present expert consensus opinion and associated recommendations. It is recommended that in aircrew with non-obstructive coronary artery disease or obstructive coronary artery disease not deemed haemodynamically significant, nor meeting the criteria for excessive burden (based on plaque morphology and aggregate stenosis), a return to flying duties may be possible, although with restrictions. It is recommended that aircrew with haemodynamically significant coronary artery disease (defined by a decrease in fractional flow reserve) or a total burden of disease that exceeds an aggregated stenosis of 120% are grounded. With aggressive cardiac risk factor modification and, at a minimum, annual follow-up with routine non-invasive cardiac evaluation, the majority of aircrew with coronary artery disease can safely return to flight duties.

scholarly journals Management of established coronary artery disease in aircrew with previous myocardial infarction or revascularisation

Heart ◽  
2018 ◽  
Vol 105 (Suppl 1) ◽  
pp. s31-s37 ◽  
Author(s):  
Eddie D Davenport ◽  
Thomas Syburra ◽  
Gary Gray ◽  
Rienk Rienks ◽  
Dennis Bron ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Residual Disease ◽  
Expert Consensus ◽  
Cardiac Risk Factor ◽  
Medical Examiner ◽  
Established Coronary Artery Disease ◽  
St Elevation ◽  
Artery Disease

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

Percutaneous coronary intervention in stable coronary artery disease

2014 ◽  
Vol 155 (49) ◽  
pp. 1952-1959
Author(s):  
Zsolt Piróth
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Stable Coronary Artery Disease ◽  
Coronary Intervention ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Percutaneous Coronary ◽  
Artery Disease

Percutaneous coronary intervention is a well-established symptomatic therapy of stable coronary artery disease. Using a literature search with special emphasis on the newly-published FAME 2 trial data, the author wanted to explore why percutaneous coronary intervention fails to reduce mortality and myocardial infarction in stable coronary artery disease, as opposed to surgical revascularisation. In the FAME 2 trial, fractional flow reserve-guided percutaneous coronary intervention with second generation drug eluting stents showed a significant reduction in the primary composite endpoint of 2-year mortality, myocardial infarction and unplanned hospitalization with urgent revascularisation as compared to medical therapy alone. In addition, landmark analysis showed that after 8 days, mortality and myocardial infarction were significantly reduced. The author concludes that percutaneous coronary intervention involving fractional flow reserve guidance and modern stents offers symptomatic, as well as prognostic benefit. Orv. Hetil., 2014, 155(49), 1952–1959.

scholarly journals Coronary Artery Bypass Grafting or Fractional Flow Reserve–Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease

2020 ◽  
Vol 13 (10) ◽  
Author(s):  
Giuseppe Di Gioia ◽  
Nina Soto Flores ◽  
Danilo Franco ◽  
Iginio Colaiori ◽  
Jeroen Sonck ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Hazard Ratio ◽  
Diabetic Patients ◽  
Multivessel Coronary Artery Disease ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Cerebrovascular Events ◽  
Artery Disease

Background: In diabetic patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) has shown long-term benefits over percutaneous coronary intervention (PCI). Physiology-guided PCI has shown to improve clinical outcomes in multivessel coronary artery disease, though its impact in diabetic patients has never been investigated. We evaluated long-term clinical outcomes of diabetic patients with multivessel coronary artery disease treated with fractional flow reserve (FFR)–guided PCI compared with CABG. Methods: From 2010 to 2018, 4622 diabetic patients undergoing coronary angiography were screened for inclusion. The inclusion criterion was the presence of at least 2-vessel disease defined as with diameter stenosis ≥50%, in which at least 1 intermediate stenosis (diameter stenosis, 30%–70%) was treated or deferred according to FFR. Inverse probability of treatment weighting analysis was used to account for baseline differences with a contemporary cohort of patients treated with CABG. The primary end point was major adverse cardiovascular and cerebrovascular events, defined as all-cause death, myocardial infarction, revascularization, or stroke. Results: A total of 418 patients were included in the analysis. Among them, 209 patients underwent CABG and 209 FFR-guided PCI. At 5 years, the incidence of major adverse cardiovascular and cerebrovascular events was higher in the FFR-guided PCI versus the CABG group (44.5% versus 31.9%; hazard ratio, 1.60 [95% CI, 1.15–2.22]; P =0.005). No difference was found in the composite of all-cause death, myocardial infarction, or stroke (28.8% versus 27.5%; hazard ratio, 1.05 [95% CI, 0.72–1.53]; P =0.81). Repeat revascularization was more frequent with FFR-guided PCI (24.9% versus 8.2%; hazard ratio, 3.51 [95% CI, 1.93–6.40]; P <0.001). Conclusions: In diabetic patients with multivessel coronary artery disease, CABG was associated with a lower rate of major adverse cardiovascular and cerebrovascular events compared with FFR-guided PCI, driven by a higher rate of repeat revascularization. At 5-year follow-up, no difference was observed in the composite of all-cause death, myocardial infarction, or stroke between CABG and FFR-guided PCI. Graphic Abstract: A graphic abstract is available for this article.

scholarly journals Increased Epicardial Fat Tissue is Predictor for Patients with Ischemia and No Obstructive Coronary Artery Disease

2020 ◽  
Vol 17 (4) ◽  
Author(s):  
Lin Qi ◽  
Kailei Shi ◽  
Xinkai Qu ◽  
Dingbiao Mao ◽  
Ming Li
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Cardiac Computed Tomography ◽  
Obstructive Coronary Artery Disease ◽  
Multiple Logistic Regression Analysis ◽  
Control Group ◽  
Fractional Flow ◽  
Cardiac Computed Tomography Angiography ◽  
Flow Reserve ◽  
Artery Disease

Background: Epicardial adipose tissue (EAT) may play a vital role in the progression of ischemia and no obstructive coronary artery disease (INOCA). CT can achieve a precise quantification of EAT for its higher spatial resolution compared to other methods. Objectives: This study aimed at exploring EAT in patients with INOCA, and its associations with other clinical factors. Methods: From January 2017 to October 2018, a total of 254 consecutive patients suspected with coronary atherosclerotic disease (CAD) underwent cardiac computed tomography angiography (CCTA). There were 195 patients who were excluded for obstructive CAD by CCTA analysis and CT derived fractional flow reserve (CT-FFR) (≤ 0.80). Seventy-two patients with either angina and/or signs of ischemia but without obstructive CAD were recruited as INOCA group. Forty-eight controls without angina and risk factors for INOCA were enrolled as the control group. EAT volume and thickness, and other factors were analyzed in INOCA and control groups. Results: Despite similar body mass index (BMI), EAT thickness and volume were significantly elevated in INOCA patients compared with the control group (P < 0.001). Receiver operating characteristic curve analysis for identifying INOCA exhibited a higher area under the curve of EAT volume (0.773, 95%CI 0.616-0.930) than EAT thickness (0.692, 95%CI 0.597-0.786). The cut-off values for EAT thickness and volume were 3.2 mm and 179.6 cm3, respectively. Presence of hypertension, triglyceride levels, and EAT thickness and volume were significantly associated with INOCA and lowly affected by other factors in multiple logistic regression analysis. Conclusions: INOCA patients have more EAT compared with controls. EAT is a marker of INOCA and may be a predictor of pharmacological therapy and a prognostic indicator. Further research should focus on the myocardial microcirculation changes by EAT volume reduction.

scholarly journals Coronary microvascular dysfunction in stable ischaemic heart disease (non-obstructive coronary artery disease and obstructive coronary artery disease)

2020 ◽  
Vol 116 (4) ◽  
pp. 771-786 ◽  
Author(s):  
Udo Sechtem ◽  
David Brown ◽  
Shigeo Godo ◽  
Gaetano Antonio Lanza ◽  
Hiro Shimokawa ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Obstructive Coronary Artery Disease ◽  
Microvascular Dysfunction ◽  
Diagnostic Methods ◽  
Coronary Microvascular Dysfunction ◽  
Fractional Flow ◽  
Complex Situation ◽  
Flow Reserve ◽  
Artery Disease

Abstract Diffuse and focal epicardial coronary disease and coronary microvascular abnormalities may exist side-by-side. Identifying the contributions of each of these three players in the coronary circulation is a difficult task. Yet identifying coronary microvascular dysfunction (CMD) as an additional player in patients with coronary artery disease (CAD) may provide explanations of why symptoms may persist frequently following and why global coronary flow reserve may be more prognostically important than fractional flow reserve measured in a single vessel before percutaneous coronary intervention. This review focuses on the challenges of identifying the presence of CMD in the context of diffuse non-obstructive CAD and obstructive CAD. Furthermore, it is going to discuss the pathophysiology in this complex situation, examine the clinical context in which the interaction of the three components of disease takes place and finally look at non-invasive diagnostic methods relevant for addressing this question.

scholarly journals Effects of left ventricular mass index on computed tomography derived fractional flow reserve in significant obstructive coronary artery disease

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
T Tsugu ◽  
K Tanaka ◽  
D Belsack ◽  
H Devos ◽  
Y Nagatomo ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Wall Thickness ◽  
Obstructive Coronary Artery Disease ◽  
Left Ventricular ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Vessel Morphology ◽  
Lv Mass ◽  
Artery Disease

Abstract Background In significant obstructive coronary artery disease (SOCAD), a mismatched assessment of the severity of coronary artery stenosis may occur between invasive coronary angiography and computed tomography (CT) derived fractional flow reserve (FFRCT). The exact mechanisms of unexpected underestimation of FFRCT remain unknown. Purpose The aims of this study are (1) to clarify the mechanisms of underestimation on FFRCT; and (2) to identify the predictive factors of FFRCT underestimation above the value of 0.80 in SOCAD vessels. Methods A total of 1160 outpatients who underwent CT angiography (CTA) with FFRCT analysis for suspected coronary artery disease (CAD) between January 2017 and June 2020 were evaluated. Among them, 141 consecutive patients who had both CTA coupled to FFRCT analysis and invasive angiogram showing &gt;75% coronary stenosis were included for analysis. Vessels were divided into two groups according to FFRCT at the distal vessel: FFRCT &gt;0.80 (n=12) and FFRCT ≤0.80 (n=153). Vessel-related parameters, including vessel morphology (vessel length and lumen volume) and plaque components (non-calcified plaque volume and calcified plaque volume) and left ventricular (LV) myocardial-related parameters, including LV wall thickness at each site of the myocardium, and LV mass were evaluated semi-automatically. Results Vessel morphology and plaque components did not differ between FFRCT &gt;0.80 and ≤0.80, whereas LV wall thickness (average; 10.7±2.7 vs. 8.4±1.6 mm, and maximal; 13.5±3.0 vs. 10.6±1.8 mm, all p value &lt;0.001), LV mass (136.4±38.4 vs. 98.8±26.8 g, p&lt;0.001), and LV mass index (73.8±22.6 vs. 51.8±12.2 g/m2, p&lt;0.001) were significantly higher in FFRCT &gt;0.80. Next, we investigated the parameters that correlated with FFRCT. Of all, vessel morphology and plaque components were not related to FFRCT, whereas maximal LV wall thickness, r=0.24, p=0.01; LV mass, r=0.19. p=0.04; and LV mass index, r=0.30, p=0.001) correlated with FFRCT. In the vessels showing FFRCT &gt;0.80, only LV mass (r=0.84, p=0.005) and LV mass index (r=0.67, p=0.047) correlated with FFRCT. (Figure 1). LV mass index was the strongest predictor of a distal FFRCT of &gt;0.80 with the area under curve (AUC) 0.81, 95% CI 0.62 – 1.00, P&lt;0.0001 and an optimal cut-off value of 66.5 g/m2 sensitivity 77.8%, specificity 89.6% (Figure 2). Conclusions FFRCT is affected not by vessel-related parameters but LV myocardial-related parameters in SOCAD. The presence of an excessive LV mass is a major predictor of underestimation of FFRCT in SOCAD vessels. LV myocardial-related parameters should be considered when interpreting numerical values of FFRCT to avoid the possibility of overlooked SOCAD. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

scholarly journals Effect of plaque characteristics on ischemia by invasive fractional flow reserve in nonobstructive versus obstructive coronary artery disease: results from the CREDENCE trial

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
U Gianni ◽  
I.J Van Den Hoogen ◽  
A.R Van Rosendael ◽  
A.M Bax ◽  
S.W Tantawy ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Fractional Flow Reserve ◽  
Obstructive Coronary Artery Disease ◽  
Coronary Vessel ◽  
Funding Source ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Diagnostic Certainty ◽  
Artery Disease

Abstract Background Mismatches between the severity of coronary stenosis and the presence of ischemia by invasive fractional flow reserve (FFR) are frequently reported. Purpose To investigate whether plaque characteristics as evaluated with coronary computed tomography angiography (CCTA) may explain this discordance in nonobstructive versus obstructive coronary artery disease (CAD). Methods From the CREDENCE trial, 612 patients with suspected CAD at 13 sites (64±10 years, 70% men) underwent CCTA with semi-automated whole heart quantification and invasive coronary angiography with 3-vessel FFR measurements. Obstructive CAD was visually defined as ≥50% stenosis. The primary endpoint of coronary vessel-specific ischemia was defined as FFR ≤0.80. Generalized estimating equations were calculated to evaluate the effect of plaque characteristics on coronary vessel-specific ischemia. Interactions were tested by obstructive CAD, adjusted for age. Results Among 1,686 vessels, ischemia was present in 436 (26%) vessels. In both nonobstructive and obstructive CAD, the majority of plaque characteristics were associated with coronary vessel-specific ischemia (p≤0.005, Figure 1). In nonobstructive CAD, odds for ischemia were significantly higher for total percent atheroma volume (PAV, p&lt;0.001), calcified PAV (p&lt;0.001), noncalcified PAV &lt;350 and &lt;130 HU (p≤0.043), the number of lesions at a bifurcation (p=0.009) and the number of lesions with high-risk plaque (HRP, p=0.033) when compared with obstructive CAD. Conclusion Our findings reveal that ischemia by FFR is documented in the setting of both nonobstructive and obstructive CAD on CCTA. Detection of atherosclerotic plaque characteristics associated with ischemia can potentially improve diagnostic certainty and guide management of symptomatic patients with nonobstructive CAD. Figure 1. Odds ratios for ischemia. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health - National Heart, Lung, and Blood Institute

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