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Tag: Angiography

  • Non-invasive imaging test identifies patients needing heart procedures

    Non-invasive imaging test identifies patients needing heart procedures

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    A new study showed that a non-invasive imaging test can help identify patients with coronary artery blockage or narrowing who need a revascularization procedure. The findings were published as a Special Report in Radiology: Cardiothoracic Imaging, a journal of the Radiological Society of North America (RSNA).

    Doctors use coronary CT angiography (CTA) to diagnose narrowed or blocked arteries in the heart. A CTA exam receives a score from mild (0-1) to moderate (2-3) to severe (4-5). Patients with scores above 3 typically require medical treatments and can potentially benefit from stents or surgeries (revascularization) to restore blood flow to the heart.

    CTA tells you the degree to which a vessel is blocked. But the degree of blockage doesn’t always reliably predict the amount of blood flow in the vessel.”


    Mangun Kaur Randhawa, M.D., post-doctoral research fellow, Department of Radiology at Massachusetts General Hospital (MGH), Boston

    Doctors have traditionally relied on an invasive procedure known as invasive coronary angiography to image vessels and more recently have added other invasive tests like fractional flow reserve (FFR) to identify and assess significant blockages in the vessels. CT-FFR is a relatively new alternative that non-invasively models a patient’s coronary blood flow using CTA images of the heart, AI algorithms and/or computational fluid dynamics.

    To assess the impact of the selective use of CT-FFR on clinical outcomes, Dr. Randhawa’s research team conducted a retrospective study of patients who underwent coronary CTA at MGH between August 2020 and August 2021.

    During the study period, 3,098 patients underwent coronary CTA. Of these, 113 coronary bypass grafting patients were excluded. Of the remaining 2,985 patients, 292 (9.7%) were referred for CT-FFR analysis, and eight of these exams were excluded, leaving a final study group of 284.

    As expected, most referrals to CT-FFR were patients with scores of 3 or above. CT-FFR was requested in the majority (73.5 %) of patients with a score of 3 (moderate narrowing/blockage).

    “In patients with moderate narrowing or blockage of the arteries, there can be ambiguity about who would benefit from invasive testing and revascularization procedures,” Dr. Randhawa said. “CT-FFR helps us identify and select those patients who are most likely to benefit.”

    Out of the 284 patients, 160 (56.3%) had a negative CT-FFR result of > 0.80, 88 patients (30.9%) had a clearly positive (abnormal) result of ≤ 0.75, and the remaining 36 patients (12.6%) had a borderline result between 0.76-0.80.

    Patients with significant narrowing/blockages on coronary CTA who underwent CT-FFR had lower rates of invasive coronary angiography (25.5% vs. 74.5%) and subsequent percutaneous coronary intervention (21.1% vs. 78.9%) than patients who were not referred for a CT-FFR.

    “CT-FFR helps us identify patients who would most benefit from undergoing invasive procedures and to defer stenting or surgical treatment in patients who likely won’t,” said senior author Brian B. Ghoshhajra, M.D., M.B.A., associate chair for operations and academic chief of cardiovascular imaging at MGH. “CT-FFR makes the CT ‘better’, but we found that the benefits were highest when used selectively.”

    Dr. Ghoshhajra added that their CT-FFR analysis was successful in the large majority of patients, regardless of challenging factors such as elevated or irregular heart rates and obesity.

    “When you objectively measure coronary artery flow with CT-FFR, you induce fewer patients to be further investigated and treated, because you tend to treat not just what the eyeball sees, but what the physiology supports,” he said.

    The researchers said the study results demonstrate the utility of CT-FFR in clinical practice, when used selectively, highlighting its potential to reduce the frequency of invasive procedures in patients with significant coronary artery narrowing or blockages without compromising safety.

    Source:

    Radiological Society of North America

    Journal reference:

    Randhawa, M. K., et al. (2024). Selective Use of CT Fractional Flow at a Large Academic Medical Center: Insights from Clinical Implementation after 1 Year of Practice. Radiology. Cardiothoracic Imaging. doi.org/10.1148/ryct.230073.

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  • Beta-blockers show no benefit for heart attack patients with normal heart function

    Beta-blockers show no benefit for heart attack patients with normal heart function

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    In a recent study published in The New England Journal of Medicine, researchers conducted the Randomized Evaluation of Decreased Usage of Beta-Blockers after Acute Myocardial Infarction (REDUCE-AMI) trial to determine whether long-term oral beta-blocker therapy could reduce the risk of any cause or incident MI-related mortality among individuals with acute myocardial infarction but preserved left ventricular ejection fraction compared to no beta-blocker treatment.

    Study: Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction. Image Credit: aipicte / ShutterstockStudy: Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction. Image Credit: aipicte / Shutterstock

    Background

    Beta-blockers are beneficial in treating heart failure patients and those with reducing ejection fractions; however, these findings are from 1980s trials of patients with massive myocardial infarctions and systolic dysfunction in the left ventricle. Meta-analytical research indicated that beta-blockers do not appear to lower mortality in contemporary reperfusion techniques.

    There is a lack of data from recent randomized clinical studies on the efficacy of long-term use of beta-blockers among acute myocardial infarction patients with intact ejection fraction. Previous Cochrane reviews underscore the need for novel research studies in this target population. Despite the absence of convincing scientific evidence of medication benefit, current recommendations strongly advocate beta-blocker therapy following a myocardial infarction.

    About the study

    In the present open-label, prospective, parallel-group trial, researchers evaluated the impact of beta-blocker therapy on reducing mortality among acute MI patients.

    The team conducted the registry-based trial between September 2017 and May 2023 at 45 sites across New Zealand, Sweden, and Estonia. They randomized participants with prior acute MI who underwent coronary angiographies and had ≥50% ejection fraction from the left ventricle to receive 1:1 long-term therapy with beta-blockers such as ≥100 mg/day of metoprolol or ≥5 mg/day of bisoprolol (intervention group) or no such therapy.

    All participants had obstructive coronary heart disease, as determined from coronary angiographies (i.e., ≥50% stenosis, ≤0.8 fractional flow reserves, or ≤0.9 instant wave-free segment ratios) before randomization. The primary outcome was the composite measure of all-cause or incident MI-related mortality. Secondary outcomes included cardiovascular disease-related mortality and hospital admission for atrial fibrillations or heart failure.

    Safety outcomes included hospital admission for hypotension, second and third-degree atrioventricular blocks, bradycardia, syncope, or pacemaker implantation, and hospital admission due to chronic obstructive pulmonary disease (COPD), asthma, or stroke. Other endpoints included dyspnea [diagnosed using the New York Heart Association (NYHA) recommendations] and angina pectoris (diagnosed using the Canadian Cardiovascular Society guidelines) six to 10.0 weeks or 11.0 to 13.0 months after treatment. The team used Cox proportional-hazards regressions to determine the hazard ratios (HR) for analysis. They performed sensitivity analyses, adjusting for age, country, diabetes, and prior myocardial infarction. The Swedish population registry provided data on death or emigration, and the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) register collected data on incident myocardial infarctions. The national cause-of-death registry provided cardiovascular-related mortality data, while the national patient registry provided data on atrial fibrillation, heart failure, and safety outcomes.

    Results

    The researchers enrolled 5,020 MI patients (95% from Sweden) who followed up for a median of 3.50 years until November 16, 2023. The median participant age was 65.0 years, 23% were female, and 35% had myocardial infarction with an elevation in the ST segment. Among the participants, 46% were hypertensive, 14% were diabetic, and 7.1% had a prior myocardial infarction. Of 2,508 beta-blocker recipients, 1,560 (62%) and 948 (38%) received metoprolol and bisoprolol, respectively.

    Coronary angiography showed one-vessel involvement among 55% of MI patients, two vessels involved among 27%, and three vessels involved among 17% of patients. The team performed percutaneous coronary interventions in 96% of patients, with coronary artery bypass grafting (CABG) among 3.9%. At hospital discharge, 97% received aspirin, P2Y12 receptor blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins.

    The researchers observed the primary endpoint among 7.9% (199 out of 2,508) of beta-blocker recipients and 8.3% (208 out of 2,512) of non-recipients (HR, 0.96). Beta-blockers did not lower the cumulative incidence rates of secondary endpoints (all-cause mortality, 3.90% and 4.10% among beta-blocker recipients and non-recipients, respectively); cardiovascular disease-related mortality, 1.50% and 1.30%, respectively; myocardial infarctions, 4.50% and 4.70%; hospital admission due to atrial fibrillations, 1.10% and 1.40%; and hospital admission due to heart failures, 0.80% and 0.90%).

    Concerning safety endpoints, the researchers observed hospital admission due to atrioventricular blocks, bradycardia, syncope, hypotension, or pacemaker implantation among 3.40% of beta-blocker recipients and 3.20% of non-recipients; hospital admission due to COPD or asthma in 0.60% and 0.60%, respectively, and hospital admission due to stroke among 1.40% and 1.80% of beta-blocker recipients and non-recipients, respectively. Subgroup analyses yielded similar results.

    Overall, the study findings showed that long-term use of beta-blockers did not reduce the risk of all-cause or incident myocardial infarction-related mortality in patients with an acute MI who underwent coronary angiography but retained ≥50% ejection fraction from the left ventricle compared to no treatment with beta-blockers.

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  • Ultrahigh-spatial-resolution PCD-CT improves assessment of coronary artery disease

    Ultrahigh-spatial-resolution PCD-CT improves assessment of coronary artery disease

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    Ultrahigh-spatial-resolution photon-counting detector CT improved assessment of coronary artery disease (CAD), allowing for reclassification to a lower disease category in 54% of patients, according to a new study published today in Radiology, a journal of the Radiological Society of North America (RSNA). The technology has the potential to improve patient management and reduce unnecessary interventions.

    Coronary CT angiography is a first-line test in the assessment of coronary artery disease. However, its diagnostic value is limited in patients with severe calcifications, or calcium buildup in the plaque of the coronary arteries.

    Ultrahigh-spatial-resolution photon-counting detector CT (PCD-CT) improves image quality compared to conventional CT. Additionally, it provides better spatial resolution, or the ability to differentiate two adjacent structures as being distinct from one another.

    Our study provides a glimpse into the potential impact of performing coronary CT angiography using ultrahigh spatial resolution technology on risk reclassification and recommended downstream testing.” 

    Tilman Emrich, M.D., study co-author, attending radiologist at the University Medical Center Mainz in Germany, and assistant professor of radiology at the Medical University of South Carolina in Charleston

    For the study, researchers evaluated coronary stenoses, or narrowing in the coronary arteries, in a vessel phantom (in-vitro) containing two different stenosis grades (25%, 50%), and retrospectively in 114 patients (in-vivo) who underwent ultrahigh-spatial-resolution cardiac PCD-CT for the evaluation of coronary artery disease. In-vitro values were compared to the phantom’s manufacturer specifications, and patient results were assessed regarding effects on coronary artery disease reporting and data system reclassification (CAD-RADS).

    “The study used a combination of artificial vessel models and real-world patient data,” Dr. Emrich said. “It simulated three types of reconstructions from a single PCD-CT scan, resembling conventional CT, high-resolution, and ultrahigh-spatial-resolution scans. Observers evaluated the severity of stenosis and generated CAD-RADS classifications, guiding further patient management decisions.”

    In-vitro results demonstrated a reduced overestimation of the stenosis by ultrahigh-spatial-resolution scans by reducing the adverse effects of the calcifications on the image.

    Results from the patients with suspected or diagnosed coronary artery disease confirmed a lower median degree of stenosis for calcified plaques (29% vs. 42%) with ultrahigh-spatial-resolution PCD-CT compared to standard CT. Ultrahigh-spatial-resolution often led to patients being reclassified to a lower CAD-RADS category. Of the 114 patients, 54% were given a lower CAD-RADS classification than they were originally assigned. The researchers found in-vitro quantification of the 193 coronary CT angiography-based stenoses was also more accurate using ultrahigh-spatial-resolution than standard resolution.

    “We found that ultrahigh-spatial-resolution reconstructions resulted in significant changes in recommendations for over 50% of patients,” Dr. Emrich said. “The impact was particularly notable in cases with calcified plaques, where ultrahigh-spatial-resolution reduced the overestimation of stenosis.”

    Dr. Emrich explained that ultrahigh-spatial-resolution may address the current limitations of conventional cardiac CT angiography by reducing the overestimation of stenosis due to calcium blooming, an effect which can cause small, high-density structures-;such as calcifications-;to appear larger than their true size.

    “This could significantly alter recommendations for downstream testing, potentially leading to a reduction of unnecessary procedures (and their potential complications) and reduced healthcare costs,” he said.

    No substantial benefits of ultrahigh-spatial-resolution were observed for mixed and non-calcified plaques.

    “It is important to note that these findings are from a simulation study, and further validation is needed in real-world comparisons,” Dr. Emrich said.

    “Ultrahigh-Spatial-Resolution Photon-counting Detector CT Angiography of Coronary Artery Disease for Stenosis Assessment.” Collaborating with Dr. Emrich were Moritz C. Halfmann, M.D., Stefanie Bockius, M.D., Michaela Hell, M.D., U. Joseph Schoepf, M.D., Gerald S. Laux, M.D., Larissa Kavermann, M.D., Dirk Graafen, M.D., Tomasso Gori, M.D., Ph.D., Yang Yang, M.D., Roman Klöckner, M.D., Pál Maurovich-Horvat, M.D., Ph.D., Jens Ricke, M.D., Lukas Müller, M.D., Akos Varga-Szemes, M.D., Ph.D., and Nicola Fink, M.D.

    Source:

     Radiological Society of North America

    Journal reference:

    Halfmann, M. C., et al. (2024) Ultrahigh-Spatial-Resolution Photon-counting Detector CT Angiography of Coronary Artery Disease for Stenosis Assessment. Radiology. doi.org/10.1148/radiol.231956.

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  • CT scans may be better first step for evaluating chest pain

    CT scans may be better first step for evaluating chest pain

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    Previous studies have found less than 40% of patients with stable chest pain undergoing invasive coronary angiography are found to have obstructive coronary artery disease. Recent randomized clinical trials have demonstrated a benefit to using computed tomography angiography (CTA) first in evaluation of these patients, and a new study being presented at the American College of Cardiology Cardiovascular Summit lends credence to this strategy, finding that CT was associated with a higher likelihood of revascularization compared to other imaging modalities or no testing.

    Stable angina is a type of chest discomfort that occurs when the heart muscle needs more oxygen than usual-;such as during stress, exercise or cold weather-;but it’s not getting it, often due to blocked coronary arteries. Patients with stable angina are often treated with guideline-directed medical therapy and lifestyle changes but may also need a coronary revascularization procedure to restore adequate blood flow to resolve their symptoms.

    Right now, when a patient presents to their primary care physician or cardiologist with symptoms suspicious for angina, they are commonly referred for additional testing.”


    Markus Scherer, MD, Director of Cardiac CT and Structural Heart Imaging at Atrium Health-Sanger Heart & Vascular Institute and study’s senior author

    Between October 2022 and June 2023, researchers at Atrium Health-Sanger Heart & Vascular Institute in Charlotte, North Carolina, assessed 786 patients who had no prior diagnosis of coronary artery disease and underwent elective invasive coronary angiography (ICA) for the evaluation of suspected angina. The pre-ICA testing strategies were: no noninvasive testing with direct referral to ICA (44%), stress echocardiogram (3%), stress myocardial perfusion imaging (15%), stress MRI (2%) and coronary CTA (36%). The study cohort had a mean age of 66 years, was 63% male, 37% female, 81% White, 13% Black, 1% Asian, 1% Hispanic and 1% other.

    The researchers compared rates of subsequent revascularization between patients whose initial evaluation was coronary CTA versus stress testing or clinical judgement (no testing). The “CT first” strategy was associated with subsequent revascularization in 62% of patients compared to 34% for the combination of other modalities or direct ICA referral.

    The 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain suggests either non-invasive functional imaging or coronary CTA as the initial test without specifying a preference for one or the other.

    According to the researchers, there are a multitude of reasons health systems don’t currently use a CT first approach, including the availability of high-quality CT scanners; availability of qualified cardiac CT interpreting physicians; and challenges in transitioning to a newer approach after decades of pre-established patterns (i.e. stress testing). Furthermore, a CT first approach is predominately advocated for patients with unestablished coronary artery disease and does not apply to all, as some patient factors may reduce the accuracy and utility of coronary CTA. 

    “While care must be individualized, for patients with unknown or unestablished coronary artery disease, the transition to a ‘CT first’ strategy should be a high priority for cardiovascular care providers,” Scherer said. “The non-invasive approach has a lower risk and cost than a diagnostic heart catheterization and, for the CT approach-;but not stress testing-;provides information on the absence, presence and extent of coronary atherosclerosis and whether or not there are high risk plaques as well as vessel blockages, which helps streamline patient management and risk reduction.”

    Since coronary CTA is less expensive than both nuclear myocardial perfusion imaging and ICA, there is a direct cost saving to patients and third-party payers with the CT first approach, according to Scherer. From the perspective of a health system, the most financially efficient evaluation approach becomes more important during the transition to a value-oriented health care system.

    According to the authors, the study demonstrates “real world” credence to the randomized trials showing similar benefits to a “CT first” strategy and should promote increased adoption of this strategy for the evaluation of patients with chest pain and an unestablished history of coronary artery disease.

    “Cardiac catheterization labs are a capital and human resource intensive care environment. Using them for their maximum potential of treating disease, rather than diagnosing it, bring the highest yield for these resources to the health care system,” Scherer said.

    The full results of the study and other studies will be presented at the ACC Cardiovascular Summit 2024 in Washington, on February 1-3, 2024. The ACC Cardiovascular Summit 2024 will examine innovative strategies and emerging trends in CV care, assess operational efficiencies to enhance the effectiveness of the CV service line, and adopt customizable approaches that support economic sustainability.

    Source:

    American College of Cardiology

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