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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Identification of "surgical" coronary anatomy by exercise radionuclide cineangiography
1Cardiology Division, New York Hospital-Cornell Medical Center, New York 10021.
Insights
Exercise radionuclide cineangiography accurately identifies coronary artery disease patients benefiting from mechanical therapy. Changes in ejection fraction and blood pressure during exercise are key predictors, especially in those with preserved ventricular function.
Area of Science:
- Cardiology
- Nuclear Medicine
- Cardiovascular Imaging
Background:
- Radionuclide cineangiography with exercise identifies coronary arteriographic patterns for which bypass grafting prolongs life.
- Previous studies included patients with severe myocardial damage, unlike randomized trials that excluded those with compromised function.
- Coronary anatomy patterns benefiting from mechanical therapy have been refined, with varying stenosis criteria across trials.
Purpose of the Study:
- To identify patients eligible for surgical therapy with moderately preserved ventricular function (ejection fraction ≥30%).
- To determine the accuracy of exercise parameters versus rest variables in identifying coronary anatomy patterns suitable for mechanical therapy.
- To identify the most powerful independent covariates for predicting outcomes in patients with "surgical" coronary anatomy.
Main Methods:
- Focused on patients with ejection fraction ≥30% at rest.
- Utilized radionuclide cineangiography with exercise.
- Employed logistic regression to identify independent covariates.
Main Results:
- Exercise parameters were more accurate than rest variables in identifying patients for mechanical therapy.
- Ejection fraction change with exercise and systolic blood pressure change with exercise were the most powerful covariates for "surgical" coronary anatomy (70% stenosis).
- At 50% stenosis, blood pressure change and angina class were more powerful than absolute exercise ejection fraction; a stroke work analog was most accurate.
Conclusions:
- Exercise radionuclide cineangiography, particularly changes in ejection fraction and blood pressure, is crucial for identifying coronary artery disease patients who benefit from mechanical therapy.
- Ventricular function at rest (ejection fraction ≥30%) is a key eligibility criterion.
- Specific exercise-induced hemodynamic changes are more predictive than resting or absolute exercise values in defining optimal mechanical therapy candidates.
Abstract:
Radionuclide cineangiography with exercise has been used to identify patients with coronary arteriographic patterns for which bypass grafting has been shown to prolong life. However, patients with severe prior myocardial damage were included in these studies, although the randomized medicine versus surgery trials recognized an effect of resting ejection fraction on operative risk and excluded patients with severely compromised function. Moreover, continuing reports from trials of surgery and from an ancillary evaluation of angioplasty have refined the set of coronary anatomic patterns for which mechanical therapy prolongs life, although stenosis severity criteria varied (50 vs 70 to 75%) between these trials. In this study, we have focused on patients who would have been eligible for the randomized trials of surgical therapy, and included only those with at least moderately preserved ventricular function at rest (ejection fraction greater than or equal to 30%). In such patients, exercise parameters were significantly more accurate than rest variables in identifying all anatomic patterns appropriately treated mechanically; logistic regression selected ejection fraction change with exercise, followed by systolic blood pressure change with exercise, as the 2 most powerful independent covariates among patients with "surgical" coronary anatomy defined by a 70% stenosis criterion; absolute exercise ejection fraction contributed no significant independent information. When defined at a 50% stenosis severity level, blood pressure change and angina class were more powerful than absolute exercise ejection fraction, but a crude, noninvasively determined analog of stroke work, incorporating change in both ejection fraction and blood pressure, was most accurate.(ABSTRACT TRUNCATED AT 250 WORDS)
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