Project description:Background and aimsOvertesting of low-risk patients with suspect chronic coronary syndrome (CCS) is widespread. The acoustic-based coronary artery disease (CAD)-score has superior rule-out capabilities when added to pre-test probability (PTP). FILTER-SCAD tested whether providing a CAD-score and PTP to cardiologists was superior to PTP alone in limiting testing.MethodsAt six Danish and Swedish outpatient clinics, patients with suspected new-onset CCS were randomized to either standard diagnostic examination (SDE) with PTP, or SDE plus CAD-score, and cardiologists provided with corresponding recommended diagnostic flowcharts. The primary endpoint was cumulative number of diagnostic tests at one year and key safety endpoint major adverse cardiac events (MACE).ResultsIn total, 2008 patients (46% male, median age 63 years) were randomized from October 2019 to September 2022. When randomized to CAD-score (n = 1002), it was successfully measured in 94.5%. Overall, 13.5% had PTP ≤ 5%, and 39.5% had CAD-score ≤ 20. Testing was deferred in 22% with no differences in diagnostic tests between groups (P for superiority = .56). In the PTP ≤ 5% subgroup, the proportion with deferred testing increased from 28% to 52% (P < .001). Overall MACE was 2.4 per 100 person-years. Non-inferiority regarding safety was established, absolute risk difference 0.49% (95% confidence interval -1.96-0.97) (P for non-inferiority = .003). No differences were seen in angina-related health status or quality of life.ConclusionsThe implementation strategy of providing cardiologists with a CAD-score alongside SDE did not reduce testing overall but indicated a possible role in patients with low CCS likelihood. Further strategies are warranted to address resistance to modifying diagnostic pathways in this patient population.

| S-EPMC11704391 | biostudies-literature

Giant Intrapericardial Myxoma Adjacent to the Left Main Coronary Artery.

Project description:A 62-years-old woman was admitted to the hospital because of chronic cough, expectoration of thick mucus, hoarseness and tightness in the precordial area. Computed Tomography (CT) examination revealed the presence of a giant intrapericardial tumor with the dimensions of 80 × 38 × 32 mm. It was located anteriorly and laterally to the left atrium, posteriorly to the pulmonary trunk and the ascending aorta. This hypodense change modeled the left atrium without evidence of invasion. CT coronary angiography and 3-dimensional reconstruction were applied to enable precise planning of cardiac surgery. CT evaluation confirmed that it is possible to remove the tumor without damage to the adjacent left main coronary artery. The patient underwent cardiac surgery with sternotomy and cardiopulmonary bypass. A cohesive, smooth, vascularized tumor pedunculated to the left atrial epicardium was visualized. The location and dimensions corresponded to those determined by CT scan examination. The entire tumor was successfully dissected together with adjacent adipose and fibrous tissue. Histological evaluation revealed the presence of myxoid cells, blood vessels, degenerative changes, and microcalcifications embedded in profuse hyalinized stroma. Those histological features enabled identification of the intrapericardial tumor as a myxoma. Follow-up CT examination did not demonstrate any signs of recurrence of the myxoma. According to our knowledge, a myxoma located inside the pericardial sac has never been described before.

| S-EPMC6262358 | biostudies-literature

Communicating Coronary and Ventricular Pseudoaneurysms Complicating Coronary Artery Perforation.

Project description:We present the case of a 75-year-old man who experienced rebleeding after surgical treatment of grade III coronary perforation, resulting in intertwined complications including communicating coronary and ventricular pseudoaneurysms. The percutaneous intervention of sealing the rebleeding site with a covered stent implantation managed this rare pseudoaneurysm successfully. (Level of Difficulty: Advanced.).

| S-EPMC9434650 | biostudies-literature

Resting Myocardial Contrast Echocardiography for the Evaluation of Coronary Microcirculation Dysfunction in Patients With Early Coronary Artery Disease.

Project description:BackgroundCoronary microcirculation dysfunction can occur in patients with chest pain suggestive of coronary artery disease (CAD). The present study aimed to determine the diagnostic value of resting myocardial contrast echocardiography (MCE) for early CAD with myocardial microcirculation dysfunction by evaluating the continuous imaging time, peak time, and peak intensity.HypothesisResting MCE is an effective and noninvasive method for evaluation of coronary microcirculation dysfunction in patients with early coronary artery disease.MethodsThe present study included 20 consecutive patients without obvious clinical evidence of early CAD and 20 healthy volunteers. Resting MCE was performed to evaluate the myocardial microcirculation perfusion, and the follow-up evaluation of myocardial microcirculation perfusion was performed with technetium 99 m 2-methoxy-isobutyl-isonitrile ((99m) Tc-MIBI) single-photon emission computed tomography (SPECT).ResultsPeak intensity was significantly lower in patients with high risk of CAD than in controls (P < 0.0001). The peak time and continuous imaging time were significantly higher in patients with high risk of CAD than in controls (P < 0.0001). None of the 40 subjects experienced discomfort, such as cough and chest tightness, during the resting MCE procedure, and the heart rate and blood pressure showed no abnormalities during the entire procedure. SPECT imaging showed reversible myocardial perfusion reduction in 80% (16/20) of the patients with high risk of CAD. Abnormalities of heart rate and blood pressure and adverse reactions were noted during the process of SPECT examination.ConclusionsResting MCE is an effective and noninvasive method for detecting abnormalities of coronary microcirculation and can help in the clinical analysis, risk assessment, and treatment of early occult CAD.

| S-EPMC6490753 | biostudies-literature

Right coronary artery fistula with giant pseudoaneurysm presenting as intrapericardial mass.

Project description:Coronary artery fistulas are rare congenital anomalies usually discovered incidentally on imaging studies. Coronary artery pseudoaneurysms are unusual complications of coronary artery fistulas, which can be due to atherosclerosis, inflammatory, traumatic or iatrogenic causes. We present a case of a 55 year old female with no known atherosclerotic risk factors, history of trauma or connective tissue disease referred because of recurrent palpitations. Work ups revealed a cardiac mass with an initial assessment of pericardial cyst. A multi modality approach of two dimensional echocardiography with Doppler studies, multidetector computed tomography and coronary angiogram revealed coronary artery fistula draining into a pericardial mass. The patient underwent surgical excision of the mass and ligation of the feeding vessel. Histopathology revealed features suggestive of a pseudoaneurysm. Postoperative course was uneventful and she was discharged stable and improved. Coronary artery fistula complicated by pseudoaneurysm is a rare clinical entity especially in patients without history of trauma or other risk factors. It can have an unusual presentation which can confound the diagnosis. Multimodality imaging is essential and adjunctive in order to determine a conclusive assessment. <Learning objective: Coronary artery pseudoaneurysm secondary to a congenital coronary artery fistula is an unusual cardiovascular pathology and can present as a rare diagnostic challenge for the clinician. This case emphasizes the importance of meticulous integration of both clinical assessment and complementary multimodality imaging approaches to better define the best therapeutic plan and facilitation of definitive surgical management.>.

| S-EPMC6149593 | biostudies-literature

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule.

Project description:BackgroundChest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care.MethodsWe conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort).ResultsThe prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result <or= 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%).InterpretationThe prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care.

| S-EPMC2934794 | biostudies-literature

Development of a Non-Invasive Machine-Learned Point-of-Care Rule-Out Test for Coronary Artery Disease.

Project description:The current standard of care for coronary artery disease (CAD) requires an intake of radioactive or contrast enhancement dyes, radiation exposure, and stress and may take days to weeks for referral to gold-standard cardiac catheterization. The CAD diagnostic pathway would greatly benefit from a test to assess for CAD that enables the physician to rule it out at the point of care, thereby enabling the exploration of other diagnoses more rapidly. We sought to develop a test using machine learning to assess for CAD with a rule-out profile, using an easy-to-acquire signal (without stress/radiation) at the point of care. Given the historic disparate outcomes between sexes and urban/rural geographies in cardiology, we targeted equal performance across sexes in a geographically accessible test. Noninvasive photoplethysmogram and orthogonal voltage gradient signals were simultaneously acquired in a representative clinical population of subjects before invasive catheterization for those with CAD (gold-standard for the confirmation of CAD) and coronary computed tomographic angiography for those without CAD (excellent negative predictive value). Features were measured from the signal and used in machine learning to predict CAD status. The machine-learned algorithm achieved a sensitivity of 90% and specificity of 59%. The rule-out profile was maintained across both sexes, as well as all other relevant subgroups. A test to assess for CAD using machine learning on a noninvasive signal has been successfully developed, showing high performance and rule-out ability. Confirmation of the performance on a large clinical, blinded, enrollment-gated dataset is required before implementation of the test in clinical practice.

| S-EPMC11012183 | biostudies-literature

Incremental value of contrast myocardial perfusion to detect intermediate versus severe coronary artery stenosis during stress-echocardiography.

Project description:BackgroundWe aimed to compare the incremental value of contrast myocardial perfusion imaging (MPI) for the detection of intermediate versus severe coronary artery stenosis during dipyridamole-atropine echocardiography (DASE).Wall motion (WM) assessment during stress-echocardiography demonstrates suboptimal sensitivity to detect coronary artery disease (CAD), particularly in patients with isolated intermediate (50%-70%) coronary stenosis.MethodsWe performed DASE with MPI in 150 patients with a suspected chest pain syndrome who were given clinical indication to coronary angiography.Results and discussionWhen CAD was defined as the presence of a >or=50% stenosis, the addition of MPI increased sensitivity (+30%) and decreased specificity (-14%), with a final increase in total diagnostic accuracy (+16%, p < 0.001). The addition of MPI data substantially increased the sensitivity to detect patients with isolated intermediate stenosis from 37% to 98% (p < 0.001); the incremental sensitivity was much lower in patients with severe stenosis, from 85% to 96% (p < 0.05), at the expense of a higher decrease in specificity and a final decrease in total diagnostic accuracy (-18%, p < 0.001).ConclusionsThe addition of MPI on top of WM analysis during DASE increases the diagnostic sensitivity to detect obstructive CAD, whatever its definition (>or=50% or > 70% stenosis), but it is mainly driven by the sensitivity increase in the intermediate group (50%-70% stenosis).The total diagnostic accuracy increased only when defining CAD as >or=50% stenosis, since in patients with severe stenosis (> 70%) the decrease in specificity is not counterbalanced by the minor sensitivity increase.

| S-EPMC2877655 | biostudies-literature

Coronary Artery Perforation: A Rare Serious Complication of Pericardiocentesis.

Project description: Not available

| S-EPMC11308111 | biostudies-literature