Absent or Mild Coronary Calcium Predicts Low-Risk Stress Test Results and Outcomes in Patients Considered for Flecainide Therapy

2021 ◽  
pp. 107424842110466
Author(s):  
Jeffrey L. Anderson ◽  
Stacey Knight ◽  
Raymond O. McCubrey ◽  
Heidi T. May ◽  
Steve Mason ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Coronary Angiography ◽  
Stress Testing ◽  
Stress Test ◽  
Clinical Information ◽  
Major Adverse Cardiovascular Events ◽  
Quantitative Ct ◽  
Flow Reserve ◽  
History Of ◽  
Artery Disease

Background: Flecainide is a useful antiarrhythmic for atrial fibrillation (AF). However, because of ventricular proarrhythmia risk, a history of myocardial infarction (MI) or coronary artery disease (CAD) is a flecainide exclusion, and stress testing is used to exclude ischemia. We assessed whether absent/mild coronary artery calcium (CAC) can supplement or avoid the need for stress testing. Methods: We assessed ischemic burden using regadenoson Rb-82 PET/CT in 1372 AF patients ≥50 years old without symptoms or signs of clinical CAD. CAC was determined qualitatively by low dose attenuation computed tomography (CT) (n = 816) or by quantitative CT (n = 556). Ischemic burden and clinical outcomes were compared by CAC burden. Results: Patients with CAC absent or mild (n = 766, 57.2%) were younger, more frequently female, and had higher BMI but lower rates of diabetes, hypertension, and dyslipidemia. Average ischemic burden was lower in CAC-absent/mild patients, and CAC-absent/mild patients showed greater coronary flow reserve, had fewer referrals for coronary angiography, and less often had obstructive CAD. Revascularization at 90 days was lower, and the rate of longer-term major adverse cardiovascular events was favorable. Conclusions: An easily administered, inexpensive, low radiation CAC scan can identify a subset of flecainide candidates with a low ischemic burden on PET stress testing that rarely needs coronary angiography/intervention and has favorable outcomes. Absent or mild CAC-burden combined with other clinical information may avoid or complement routine stress testing. However, additional, ideally randomized and multicenter trials are indicated to confirm these findings before replacing stress testing with CAC screening in selecting patients for flecainide therapy in clinical practice.

Abstract 14840: Ability of Coronary Calcium Absence to Predict Negative Stress Test Results in Patients Considered for Flecainide Therapy

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jeffrey L Anderson ◽  
Stacey Knight ◽  
Raymond McCubrey ◽  
Heidi T May ◽  
David B Min ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Coronary Angiography ◽  
Stress Testing ◽  
Stress Test ◽  
Clinical Information ◽  
Quantitative Ct ◽  
Cardiac Arrhythmia Suppression Trial ◽  
Flow Reserve ◽  
Increased Risk ◽  
Artery Disease

Background: Flecainide is a useful antiarrhythmic for atrial fibrillation (AF). However, the Cardiac Arrhythmia Suppression Trial (CAST) showed an increased risk of fatal ventricular arrhythmia with flecainide use after myocardial infarction (MI). Thus, a history of MI or coronary artery disease (CAD) is a flecainide exclusion, and stress testing is used to exclude ischemia. We assessed whether absence of coronary artery calcium (CAC) can obviate the need for stress testing. Methods: We assessed ischemic burden using regadenoson Rb-82 PET/CT in 1375 AF patients (pts) ≥50 y old without clinical CAD. CAC was determined qualitatively in these pts by low dose attenuation CT (n=816) or by quantitative CT (n=559). The primary comparison was percentage of pts with ischemic burden ≥5% by CAC presence or absence. Results: Pts with CAC absent (n=433, 31.5%) were younger, heavier, with lower rates of diabetes, hypertension, and dyslipidemia. Average ischemic burden was lower in CAC-absent pts (0.8 ± 3.1 v 1.3 ± 3.7, p=0.04), and a favorable difference trend in ischemic burden ≥5% was noted that did not reach significance (7.2% v 9.7% p=0.15). CAC-absent pts showed greater coronary flow reserve (2.4 v 2.3, p=0.002) and trended to have fewer referrals for coronary angiography (1.6% v 4.0% adjusted[adj]*-p=0.10), fewer findings of obstructive CAD (1.4% v 3.5% adj-p=0.12), and lower rates of 90-day MACE (1.6% v 3.5%, adj-p=0.12); long-term MACE were fewer (5.3% v 7.0% adj-p=0.04). Conclusions: Our results support the hypothesis that an easily administered, inexpensive, low radiation CAC scan may identify a subset of flecainide candidates with a low ischemic burden on PET stress testing and that rarely need coronary angiography/intervention. CAC-absence combined with other clinical information may obviate the need for routine stress testing in selected flecainide candidates. Larger and randomized trials are indicated to confirm these findings and apply CAC use in clinical practice.

scholarly journals Relationship of Stress Test Findings to Anatomic or Functional Extent of Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Demetrios Doukas ◽  
Sorcha Allen ◽  
Amy Wozniak ◽  
Siri Kunchakarra ◽  
Rina Verma ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Stress Testing ◽  
Stress Test ◽  
Exercise Duration ◽  
Fractional Flow ◽  
Coronary Cta ◽  
Flow Reserve ◽  
Artery Disease

Background. In the United States, functional stress testing is the primary imaging modality for patients with stable symptoms suspected to represent coronary artery disease (CAD). Coronary computed tomography angiography (CTA) is excellent at identifying anatomic coronary artery disease (CAD). The application of computational fluid dynamics to coronary CTA allows fractional flow reserve (FFR) to be calculated noninvasively (FFRCT). The relationship of noninvasive stress testing to coronary CTA and FFRCT in real-world clinical practice has not been studied. Methods. We evaluated 206 consecutive patients at Loyola University Chicago with suspected CAD who underwent noninvasive stress testing followed by coronary CTA and FFRCT when indicated. Patients were categorized by stress test results (positive, negative, indeterminate, and equivocal). Duke treadmill score (DTS), METS, exercise duration, and chest pain with exercise were analyzed. Lesions ≥ 50 % stenosis were considered positive by coronary CTA. FF R CT < 0.80 was considered diagnostic of ischemia. Results. Two hundred and six patients had paired noninvasive stress test and coronary CTA/FFRCT results. The median time from stress test to coronary CTA was 49 days. Average patient age was 60.3 years, and 42% were male. Of the 206 stress tests, 75% were exercise (70% echocardiographic, 26% nuclear, and 4% EKG). There were no associations of stress test results with CAD > 50 % or FF R CT < 0.80 ( p = 0.927 and p = 0.910 , respectively). Of those with a positive stress test, only 30% (3/10) had CAD > 50 % and only 50% (5/10) had FF R CT < 0.80 . Chest pain with exercise did not correlate with CAD > 50 % or FF R CT < 0.80 ( p = 0.66 and p = 0.12 , respectively). There were no significant correlations between METS, DTS, or exercise duration and FFRCT ( r = 0.093 , p = 0.274 ; r = 0.012 , p = 0.883 ; and r = 0.034 , p = 0.680 ; respectively). Conclusion. Noninvasive stress testing, functional capacity, chest pain with exercise, and DTS are not associated with anatomic or functional CAD using a diagnostic strategy of coronary CTA and FFRCT.

Coronary Artery Disease Screening Using CT Coronary Angiography

2020 ◽  
Vol 91 (10) ◽  
pp. 812-817
Author(s):  
Randy Wang Long Cheong ◽  
Brian See ◽  
Benjamin Boon Chuan Tan ◽  
Choong Hou Koh
Keyword(s):  
Systematic Review ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Cardiac Risk ◽  
Disease Screening ◽  
Ct Coronary Angiography ◽  
Major Adverse Cardiovascular Events ◽  
Cardiac Events ◽  
Artery Disease

BACKGROUND: The increased utility of CT coronary angiography (CTCA) in cardiovascular screenings of aircrew has led to the increased detection of asymptomatic coronary artery disease (CAD). A systematic review of studies relevant to the interpretation of CTCA for the occupational fitness assessment of high-risk vocations was performed, with findings used to describe the development of a pathway for the aeromedical disposition of military aviators with asymptomatic CAD.METHODS: Medline was searched using the terms CT coronary angiogram and screening and prognosis. The inclusion criteria were restricted to study populations ages > 18 yr, were asymptomatic, were not known to have CAD, had undergone CTCA, and with their associations with major adverse cardiovascular events (MACE) and other relevant cardiac outcomes reported.RESULTS: Included in this systematic review were 10 studies. When compared to subjects with no or nonobstructive CAD, those with obstructive CAD on CTCA had hazard ratios (HR) for cardiac events ranging from 1.42 to 105.48. Comparing subjects with nonobstructive CAD and those without CAD on CTCA, a lower HR of 1.19 for cardiac events was found. The annual event rates of subjects with no CAD on CTCA were extremely low, ranging from 0 to 0.5%.CONCLUSIONS: Based on the findings, we suggest that CTCA should only be performed in aircrew with higher cardiac risk profiles. Those found to have no CAD or minimal CAD (i.e., 25% stenosis) in a non-left main coronary artery on CTCA can be returned to flying duties. All other results should be further evaluated with an invasive angiogram.Cheong RWL, See B, Tan BBC, Koh CH. Coronary artery disease screening using CT coronary angiography. Aerosp Med Hum Perform. 2020; 91(10):812817.

Abstract 13471: Additional Prognostic Value of Vasodilator Stress Cardiovascular Magnetic Resonance in Patients With Inconclusive Stress Test to Detect Coronary Artery Disease

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Theo Pezel ◽  
Guillaume Bonnet ◽  
Francesca Sanguineti ◽  
Marine Kinnel ◽  
Anouk Asselin ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Prognostic Value ◽  
Stress Test ◽  
Multivariable Analysis ◽  
Myocardial Scar ◽  
Major Adverse Cardiovascular Events ◽  
Inducible Ischemia ◽  
Artery Disease ◽  
Stress Cmr

Introduction: Non-invasive testing for ischemia to diagnose coronary artery disease(CAD) are frequently inconclusive(25%). Hypothesis: To assess the prognostic value of stress CMR in patients with a first inconclusive stress test. Methods: Between 2008 and 2018, consecutive patients with inconclusive stress test, defined by stress echocardiography or nuclear testing with uncertain conclusion, prospectively referred for stress CMR with dipyridamole were followed for major adverse cardiovascular events(MACE): cardiac death or myocardial infarction. An unsupervised clustering analysis was performed. Results: Of 1502 patients (62±12yrs, 59%men), 1397 completed the follow-up (median 5.5±2.3yrs). Three clusters were identified: Cluster 1 (n=524) had the highest prevalence of previous PCI, the highest presence of a myocardial scar defined, the lowest LVEF (35±7%) and the highest LV dilatation. Cluster 2 (n=406) had the highest previous CABG prevalence, preserved LVEF, absence of LV dilatation, and presence of myocardial scar. This cluster comprised predominantly male patients, with the highest rate of hypertension. Cluster 3 (n=572) had the lowest rate of previous PCI/CABG, the lowest rate of myocardial scar, predominantly female, the highest atrial fibrillation rate and body mass index. Survival analysis found significant differences across clusters for the occurrence of MACE (p=0.02). Inducible ischemia was associated with MACE occurrence in each cluster (C1, HR 2.28; 95%CI[1.31-3.99]; p=0.0028; C2, HR 3.37; 95%CI[1.97-5.75]; p<0.0001; C3, HR 2.73; 95%CI[1.67-4.46]; p<0.0001). In multivariable analysis, inducible ischemia predicted MACE in each cluster (p<0.001 for all). Conclusions: Cluster analysis identified 3 different phenotypes with distinct clinical and prognostic profiles. Within these clusters, stress CMR has an additional prognostic value to predict MACE..

Abstract 251: Clinical Symptoms and Angiographic Findings of Patients Undergoing Percutaneous Coronary Intervention without Prior Stress Testing: Insights from the NCDR

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Mouin Abdallah ◽  
John Spertus ◽  
Nestor Mercado ◽  
Brahmajee Nallamothu ◽  
Kevin Kennedy ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Stress Testing ◽  
Diagnostic Yield ◽  
Stress Test ◽  
Test Group ◽  
Coronary Intervention ◽  
Percutaneous Coronary ◽  
Artery Disease ◽  
Prior Stress

Background: Many patients undergoing elective percutaneous coronary intervention (PCI) do not have prior stress testing. It is unknown if these patients have more severe angina or obstructive coronary artery disease (CAD), whereby proceeding directly to PCI would represent sound clinical judgment and efficient use of resources. Methods: We identified elective PCIs performed between 1/1/09 - 3/31/11 in the NCDR CathPCI Registry ® and assessed for differences in angina (CCS class) and severity of CAD in those with and without pre-procedural stress testing. To further understand whether proceeding to PCI without prior stress testing could be justified because of a high pre-test probability for obstructive CAD (e.g., >70% stenosis in an epicardial coronary artery), we evaluated cardiac catheterizations performed within the registry during the same period to assess the diagnostic yield of obstructive CAD in patients with and without prior stress testing. Results: Of 246,629 elective PCIs, 89,084 (36.1%) were performed without prior stress testing. A substantial proportion of both groups undergoing PCI were asymptomatic (no stress test group: 28.9% vs. stress test group: 30.7%), with only a modest difference in the frequency of CCS class III/IV angina (16.2% vs. 11.9%; Table). No meaningful differences in the frequency of proximal LAD (29.7 % vs. 29.9%), left main (5.6% vs. 7.2%) or 3-vessel coronary artery disease (21.1% vs. 19.5%) were observed in the 2 PCI groups. Moreover, the diagnostic yield for obstructive CAD on cardiac catheterization for patients without prior stress testing (n=462,611) was 35.4%, as compared with 58.0%, 38.8%, and 24.1% for those with severe, moderate, and mild ischemia, on pre-procedural stress testing. Conclusion: For elective PCI, the current practice of proceeding to coronary angiography and PCI without prior stress testing does not identify higher risk coronary anatomy or more symptomatic patients and may not improve diagnostic yield.

scholarly journals Coronary angiography finding of exercise tread mill test positive patients in a tertiary care center

2017 ◽  
Vol 14 (1) ◽  
pp. 17-20 ◽  
Author(s):  
Amit Shrestha ◽  
Sanjeev Thapa ◽  
Sheelendra Shakya ◽  
Ravi Shahi ◽  
Chandra Mani Paudel ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Risk Factor ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Stress Test ◽  
Tertiary Care ◽  
P Value ◽  
Vessel Disease ◽  
Mill Test ◽  
Artery Disease

Background and Aims: The use of coronary angiography in diagnosing coronary artery disease is limited by its invasive property. In the other hand correct interpretation of tread mill test data and its use as a key diagnostic modality also has been a problem. The study was thus aimed to see the diagnostic accuracy of treadmill test to rule out coronary artery disease.Methods: We included all the patients who had positive tread mill stress test and underwent coronary angiography and were subsequently analyzed for presence of coronary artery disease.Results: A total of 303 patients were included with 119 males and 184 females with mean age of 53.6±10.5 yrs and 51.7±8.6 yrs respectively. Normal coronaries was seen in 114(54.0%), borderline lesion in 29 (13.7%) and significant lesion in 68 (32.2%) with 48(22.7%) having single vessel disease, 29(13.7%) double vessel disease and 14(6.6%) triple vessel disease. Coronary artery diseases was highest among diabetics (57.7%, OR 1.72 (95 % CI: 0.92 to 3.20), p value-0.08).Similarly the risk of coronary artery disease was significantly highest among patient with ≥2 risk factor (OR: 8.10,95 % CI: 4.96 to 13.24, P < 0.0001). Gender distribution showed that coronary artery disease was significantly higher in males than females (53% vs 35% respectively, OR: 2.08, 95 % CI: 1.30 to 3.32, p value-0.002).Conclusion: The value of tread mill test to predict coronary artery disease is highest in patients with two or more risk factor especially in those with diabetes with significance increased among males.

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