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Objective: The aim of this work was to investigate determinants of structural myocardial abnormalities in persons living with human immunodeficiency virus (PLWH).Methods and Results: We reviewed archived transthoracic echocardiograms (TTEs) performed on PLWH at Duke University Medical Center from 2001 to 2012. The primary outcomes were presence of left ventricular hypertrophy (LVH) or diastolic dysfunction (DD). TTEs for 498 human immunodeficiency virus-infected persons were reviewed (median age 44 years, 38% female, 72% black, 34% with hypertension, 15% with diabetes). Among those with usable images, LVH was detected in 174 of 473 persons (37%) according to LV mass criteria and in 99 of 322 persons (31%) according to American Society of Echocardiography LV mass index criteria. Definite DD was detected in 18 of 224 persons (8%). LVH was more common in PLWH with a CD4 count ≤ 200 cells/mm3 proximal to TTE (adjusted OR 1.68, 95% CI 1.08-2.62), CD4 nadir ≤ 200 cells/mm3 (adjusted OR 1.63, 95% CI 1.04-2.54) and less common in persons with viral suppression (OR 0.46, 95% CI 0.27-0.80). Lower CD4 nadirs (P = .002) and proximal CD4 counts (P = .002) were also associated with DD.Conclusions: Persons with a history of advanced human immunodeficiency virus-associated immune suppression are at higher risk of LVH and DD than infected persons with preserved immune function. [ABSTRACT FROM AUTHOR]

Hypertension is an atherosclerosis factor and is associated with cardiovascular risk. We investigated the relationship between hypertension and the presence, extent, and severity of coronary atherosclerosis in coronary computed tomographic angiography and cardiac events risk. Of 17 181 patients enrolled in the CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) who underwent ≥64-detector row coronary computed tomographic angiography, we identified 14 803 patients without known coronary artery disease. Of these, 1434 hypertensive patients were matched to 1434 patients without hypertension. Major adverse cardiac events risk of hypertension and non-hypertensive patients was evaluated with Cox proportional hazards models. The prognostic associations between hypertension and no-hypertension with increasing degree of coronary stenosis severity (nonobstructive or obstructive ≥50%) and extent of coronary artery disease (segment involvement score of 1-5, >5) was also assessed. Hypertension patients less commonly had no coronary atherosclerosis and more commonly had nonobstructive and 1-, 2-, and 3-vessel disease than the no-hypertension group. During a mean follow-up of 5.2±1.2 years, 180 patients experienced cardiac events, with 104 (2.0%) occurring in the hypertension group and 76 (1.5%) occurring in the no-hypertension group (hazard ratios, 1.4; 95% confidence intervals, 1.0-1.9). Compared with no-hypertension patients without coronary atherosclerosis, hypertension patients with no coronary atherosclerosis and obstructive coronary disease tended to have higher risk of cardiac events. Similar trends were observed with respect to extent of coronary artery disease. Compared with no-hypertension patients, hypertensive patients have increased presence, extent, and severity of coronary atherosclerosis and tend to have an increase in major adverse cardiac events. [ABSTRACT FROM AUTHOR]

Background--Age-adjusted coronary artery disease (CAD) burden identified on coronary computed tomography angiography predicts major adverse cardiovascular event (MACE) risk; however, it seldom contributes to clinical decision making because of a lack of nomographic data. We aimed to develop clinically pragmatic age- and sex-specific nomograms of CAD burden using coronary computed tomography angiography and to validate their prognostic use. Methods and Results--Patients prospectively enrolled in phase I of the CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes) were included (derivation cohort: n=21,132; 46% female) to develop CAD nomograms based on age-sex percentiles of segment involvement score (SIS) at each year of life (40-79 years). The relationship between SIS age-sex percentiles (SIS%) and MACE (all-cause death, myocardial infarction, unstable angina, and late revascularization) was tested in a nonoverlapping validation cohort (phase II, CONFIRM registry; n=3030, 44% female) by stratifying patients into 3 SIS% groups (≤50th, 51-75th, and >75th) and comparing annualized MACE rates and time to MACE using multivariable Cox proportional hazards models adjusting for Framingham risk and chest pain typicality. Age-sex percentiles were well fitted to second-order polynomial curves (men: R2=0.86±0.12; women: R2=0.86±0.14). Using the nomograms, there were 1576, 965, and 489 patients, respectively, in the ≤50th, 51-75th, and >75th SIS% groups. Annualized event rates were higher among patients with greater CAD burden (2.1% [95% confidence interval: 1.7%-2.7%], 3.9% [95% confidence interval: 3.0%-5.1%], and 7.2% [95% confidence interval: 5.4%-9.6%] in ≤50th, 51-75th, and >75th SIS% groups, respectively; P<0.001). Adjusted MACE risk was significantly increased among patients in SIS% groups above the median compared with patients below the median (hazard ratio [95% confidence interval]: 1.9 [1.3-2.8] for 51-75th SIS% group and 3.4 [2.3-5.0] for >75th SIS% group; P<0.01 for both). Conclusions--We have developed clinically pragmatic age- and sex-specific nomograms of CAD prevalence using coronary computed tomography angiography findings. Global plaque burden measured using SIS% is predictive of cardiac events independent of traditional risk assessment. [ABSTRACT FROM AUTHOR]

Fractional flow reserve derived from computed tomography angiography (FFRCT) is a noninvasive method for diagnosis of ischemic coronary lesions. To date, the diagnostic performance of FFRCT for lesions of intermediate stenosis severity remains unexamined.Among 407 vessels from 252 patients at 17 centers who underwent CT, FFRCT, invasive coronary angiography, and invasive FFR, we identified 150 vessels of intermediate stenosis by CT, defined as 30% to 69% stenosis. FFRCT, FFR, and CT were interpreted in blinded fashion by independent core laboratories. FFRCT and FFR 0.80 were considered hemodynamically significant, whereas CT stenosis ≥50% was considered obstructive. Diagnostic performance of FFRCT versus CT was assessed for accuracy, sensitivity, specificity, positive predictive values, and negative predictive values. Area under the receiver operating characteristic curve and net reclassification improvement were evaluated. For lesions of intermediate stenosis severity, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of FFRCT were 71%, 74%, 67%, 41%, and 90%, whereas accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT stenosis were 63%, 34%, 72%, 27%, and 78%. FFRCT demonstrated superior discrimination compared with CT stenosis on per-patient (area under the receiver operating characteristic curve, 0.81 versus 0.50; P=0.0001) and per-vessel basis (area under the receiver operating characteristic curve, 0.79 versus 0.53; P<0.0001). FFRCT demonstrated significant reclassification of CT stenosis for lesion-specific ischemia (net reclassification improvement, 0.45; 95% confidence interval, 0.25-0.65; P=0.01).FFRCT possesses high diagnostic performance for diagnosis of ischemic for lesions of intermediate stenosis severity. Notably, the high sensitivity and negative predictive value suggest the ability of FFRCT to effectively rule out intermediate lesions that cause ischemia. [ABSTRACT FROM AUTHOR]

Background: Clinical outcomes and resource utilization after coronary computed tomography angiography (CTA) versus myocardial perfusion single-photon emission CT (MPS) in patients with stable angina and suspected coronary artery disease (CAD) has not been examined. Objective: We determined the near-term clinical effect and resource utilization after cardiac CTA compared with MPS. Methods: We randomly assigned 180 patients (age, 57.3 ± 9.8 years; 50.6% men) presenting with stable chest pain and suspected CAD at 2 sites to initial diagnostic evaluation by coronary CTA (n = 91) or MPS (n = 89). The primary outcome was near-term angina-specific health status; the secondary outcomes were incident medical and invasive treatments for CAD, CAD health care costs, and estimated radiation dose. Results: No patients experienced myocardial infarction or death with 98.3% follow-up at 55 ± 34 days. Both arms experienced comparable improvements in angina-specific health status. Patients who received coronary CTA had increased incident aspirin (22% vs 8%; P = 0.04) and statin (7% vs −3.5%; P = 0.03) use, similar rates of CAD-related hospitalization, invasive coronary angiography, noninvasive cardiac imaging tests, and increased revascularization (8% vs 1%; P = 0.03). Coronary CTA had significantly lower total costs ($781.08 [interquartile range (IQR), $367.80–$4349.48] vs $1214.58 [IQR, $978.02–$1569.40]; P < 0.001) with no difference in induced costs. Coronary CTA had a significantly lower total estimated effective radiation dose (7.4 mSv [IQR, 5.0–14.0 mSv] vs 13.3 mSv [IQR, 13.1–38.0 mSv]; P < 0.0001) with no difference in induced radiation. Conclusion: In a pilot randomized controlled trial, patients with stable CAD undergoing coronary CTA and MPS experience comparable improvements in near-term angina-related quality of life. Compared with MPS, coronary CTA evaluation is associated with more aggressive medical therapy, increased coronary revascularization, lower total costs, and lower effective radiation dose. [Copyright &y& Elsevier]

Background: Fractional flow reserve calculated from coronary CT (FFRCT) is a novel method for determining lesion-specific ischemia. Objective: To assess the effect of CT quality on accuracy of FFRCT, we compared performance of FFRCT with severe stenosis by CT in relation to image quality; heart rate; signal-to-noise ratio (SNR); and common CT artifacts, including calcification, motion, and poor contrast enhancement. Methods: FFRCT was performed on 159 vessels in 103 patients undergoing CT, FFRCT, and FFR. Ischemia was defined as FFRCT and FFR ≤ 0.80, and severe stenosis by CT was defined by ≥50% reduction in luminal diameter. FFRCT and CT stenosis were compared with FFR, which served as the reference. Results: On a vessel basis, accuracy of FFRCT was higher than CT stenosis for satisfactory or poor quality CTs (87.5% vs 64.6%), for heart rates > 65 beats/min (100% vs 52.9%), and for SNR less than the median (26.3) (84.4% vs 64.1%). Accuracy of FFRCT was superior to CT stenosis in the presence of calcification (85.7% vs 66.7%), motion (90.5% vs 57.1%), and poor contrast opacification (100.0% vs 71.4%). Similar relations were observed for exploratory analyses of FFRCT and CT stenosis on a patient basis. In 42 subjects who underwent coronary calcium scanning, accuracy of FFRCT was 77.8% (n = 18), 100% (n = 11), and 100% (n = 13) for coronary calcium scores of 0–100, 101–400, and >400, respectively. Conclusions: Accuracy of FFRCT is superior to CT stenosis for determining lesion-specific ischemia. The performance of FFRCT remains robust across an array of factors known to adversely affect CT quality. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: Delayed cerebral ischemia (DCI) is a devastating condition that occurs secondary to aneurysmal subarachnoid hemorrhage (A-SAH). The purpose is to compare computed tomography perfusion (CTP) and digital subtraction angiography (DSA) for determining DCI in A-SAH. Materials and Methods: A retrospective study of A-SAH patients admitted at our institution between December 2004 and December 2008 was performed. CTP and DSA were obtained at days 6–8 after aneurysm rupture. Both qualitative and quantitative analyses of CT perfusion deficits were performed. DSA was categorized as presence or absence of vasospasm. The reference standard for determining DCI was based on clinical deterioration or infarction on CT or MRI. The test characteristics of CTP and DSA were calculated and their graphs of conditional probabilities were constructed using Bayesian analysis. Results: Fifty-seven patients were included; 79% (45/57) had DCI. Seventy percent (40/57) had CTP perfusion deficits; 80% (36/45) of the DCI and 33% (4/12) of no DCI patients. Sixty-three percent (36/57) had DSA demonstrating vasospasm; 73% (33/45) of the DCI and 25% (3/12) of no DCI patients. Quantitative analysis of the CTP data revealed a significant difference in cerebral blood flow values for the DCI (29.4 mL/100 g/minute) and no DCI groups (40.5 mL/100 g/minute, P = .0213). The sensitivity, specificity, and positive and negative predictive values for CTP were 0.80 (95% CI 0.68–0.92), 0.67 (95% CI 0.40–0.93), 0.90 (95% CI 0.82–0.96), 0.47 (95% CI 0.27–0.62), and for DSA were 0.73 (95% CI 0.60–0.86), 0.75 (95% CI 0.50–0.99), 0.92 (95% CI 0.82–0.98), and 0.43 (95% CI 0.26–0.53), respectively. Conclusion: CTP and DSA have similar test characteristics and Bayesian analysis for determining DCI in A-SAH patients. [ABSTRACT FROM AUTHOR]

The article presents a paper called "Incremental Prognostic Value of Cardiac Computed Tomography in Coronary Artery (CCTA) Disease Using Coronary CT Angiography Evaluation For Clinical Outcomes: An InteRnational Multicenter (CONFIRM), by Benjamin J. W. Chow, Gary Small, Yeung Yam and others. It states that the researchers sought in to compare the efficacy of different tools in determining the prognostic value of coronary artery disease (CAD). Their findings are included.

Background: Cardiac computed tomographic angiography (CCTA) permits simultaneous assessment of coronary artery disease (CAD) and left ventricular mass (LVM). While increased LVM predicts mortality and is associated with obstructive CAD, the relationship of LVM with non-obstructive CAD is unknown. Methods: We evaluated 212 consecutive patients undergoing 64-detector row CCTA at 2 sites without evident cardiovascular disease or obstructive (≥70%) CAD by CCTA. LVM was measured by CCTA using Simpson''s method of disks and indexed to body surface area (LVMI) and height to the allometric power of 2.7(LVM/ht2.7). CCTAs were evaluated by scoring a modified AHA 16-segment coronary artery model for none = 0 (0% stenosis), mild = 1 (1–49% stenosis) or moderate = 2 (50–69% stenosis). Overall CAD plaque burden was estimated by summing scores across all segments for a segment stenosis score (SSS, max = 32). Results: The mean age was 53.3 ± 12.8 with 52% female, 48% hypertensive, and 7.4% diabetic. The mean LVM was 109 ± 32.5 g; 58.5% had any coronary artery plaque. In multivariable linear regression, SSS was significantly associated with increased LVM, LVMI and LVM/ht2.7. LVM increased by 2.0 g for every 1-point increase in SSS (95% CI 0.06–3.4, p = 0.006). Agatston scores provided no additional predictive value for increased LVM above and beyond SSS. Conclusion: Non-obstructive CAD visualized by CCTA is associated with increased LVM independent of effects of clinical risk factors and calcium scoring. Whether addition of LVM to stenosis assessment in patients undergoing CCTA enhances risk prediction of future CAD events warrants investigation. [Copyright &y& Elsevier]

Background: Coronary computed tomographic angiography (CCTA) of 64-detector rows or greater represents a novel noninvasive anatomic method for evaluation of patients with suspected coronary artery disease (CAD). Early studies suggest a potential for prognostic risk assessment by CCTA findings but were limited by small patient cohorts or single centers. The CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry is a large, prospective, multinational dynamic observational study of patients undergoing CCTA. The primary aim of CONFIRM is to determine the prognostic value of CCTA findings for the prediction of future adverse CAD events. Methods: The CONFIRM registry currently represents 27,125 consecutive patients at 12 cluster sites in 6 countries in North America, Europe, and Asia. CONFIRM sites were chosen on the basis of adequate CCTA volume, site CCTA proficiency, and local demographic characteristics and medical facilities to ensure a broad-based sample of patients. Patients comprising the present CONFIRM cohort include those with suspected but without known CAD, with known CAD, or asymptomatic persons undergoing CAD evaluation. A data dictionary comprising a wide array of demographic, clinical, and CCTA findings was developed by the CONFIRM investigators and is uniformly used for all patients. Patients are followed up after CCTA performance to identify adverse CAD events, including death, myocardial infarction, unstable angina, target vessel revascularization, and CAD-related hospitalization. Conclusions: From a number of countries worldwide, the information collected from the CONFIRM registry will add incremental and important insights into CCTA findings that confer prognostic value beyond demographic and clinical characteristics. The results of the CONFIRM registry will provide valuable information about the optimal methods for using CCTA findings. [ABSTRACT FROM AUTHOR]

Background: Coronary computed tomographic angiography (CCTA) possesses high accuracy to detect coronary artery disease (CAD), although studies have reported differences in diagnostic performance. Prior trials used different numbers of interpreters, and the optimal number to detect CAD is unknown. Objective: We compared the diagnostic performance of 1, 2, 3, and 5 randomly selected interpreters for CCTA. Methods: We evaluated 50 patients randomly selected from 2 multicenter studies with both 64-detector CCTA and invasive quantitative coronary angiography (QCA). Five blinded, experienced readers independently interpreted CCTA and assessed for obstructive CAD (≥50% stenosis) and high-risk CAD (left main, proximal left anterior descending, or 3-vessel stenoses). A core laboratory performed QCA. For each patient, different random combinations of readers were selected; the accuracy of 1, 2, and 5 readers was compared with 3 readers. Results: Obstructive and high-risk CAD were observed in 20 of 50 (40%) and 6 of 50 (12%) patients, respectively. With combinations of 1, 2, 3, or 5 readers, there was a range of per-patient diagnostic performance (sensitivity, 100% each; specificity, 67%–90%; accuracy, 80%–94%; P = NS), per-segment diagnostic performance (sensitivity, 67%–83%; specificity, 87%–93%; accuracy, 87%–92%; P < .001 for 1 vs 3 and 2 vs 3 readers), and detection of high-risk CAD (sensitivity, 83%–100%; specificity, 73%–80%; accuracy, 76%–82%; P = NS). The highest diagnostic accuracy was observed with 3 readers for each comparison. Conclusion: The diagnostic performance of CCTA to detect obstructive or high-risk CAD is generally high irrespective of the number of readers. Consensus interpretation by ≥3 readers provides the highest diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Background: Coronary computed tomographic angiography (CCTA) requires iodinated contrast and often atrioventricular nodal blocking agents and nitroglycerin for heart rate lowering and coronary vasodilation, respectively. To date, the periprocedural safety of CCTA is unknown. Objectives: The purpose of this study was to evaluate the periprocedural safety of CCTA. Methods: We prospectively evaluated 232 patients with symptomatic chest pain without preexisting renal insufficiency at 16 sites who underwent CCTA as part of the Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography (ACCURACY) trial. Patients received iodinated contrast, β-blockers, and nitroglycerin as part of a predefined CCTA protocol. We assessed the rates of adverse events (AEs) related to these agents. Results: As measured by serum creatinine and creatinine clearance, no significant change was observed in renal function from baseline (1.00 ± 0.19 mg/dL; modification of diet in renal disease [MDRD]: 76.91 ± 17.96 mL/min/1.73 m2) to 48 hours (1.0 ± 0.2 mg/dL; P = 1.00; MDRD change: 0.2 ± 12.4 mL/min/1.73 m2; P = 0.83) or at 30 days (1.0 ± 0.2 mg/dL; P = 0.52; MDRD change: −0.9 ± 16.9 mL/min/1.73 m2; P = 0.77). Mean systolic blood pressure decreased from baseline (133 ± 19 mm Hg) at 1 hour (125 ± 17 mm Hg; P < 0.001) and rebounded at 48 hours (133 ± 17 mm Hg). Mean heart rate decreased from baseline (65 ± 10 beats/min) at 1 hour (60 ± 7 beats/min) but rose at 48 hours (69 ± 11 beats/min; P < 0.001. All patients were asymptomatic from baseline to follow-up. Conclusions: The performance of CCTA is safe with low rates of AEs. [ABSTRACT FROM AUTHOR]

Background Diuretic unresponsiveness often occurs during hospital admission for acute heart failure (AHF) and is associated with adverse outcome. This study aims to investigate determinants, clinical outcome, and the effects of nesiritide on diuretic response early after admission for AHF. Methods Diuretic response , defined as weight loss per 40 mg of furosemide or equivalent, was examined from hospital admission to 48 hours in 4,379 patients from the ASCEND-HF trial. As an additional analysis, a urinary diuretic response metric was investigated in 5,268 patients using urine volume from hospital admission to 24 hours per 40 mg of furosemide or equivalent. Results Mean diuretic response was −0.42 kg/40 mg of furosemide (interquartile range −1.0, −0.05). Poor responders had lower blood pressure, more frequent diabetes, long-term use of loop diuretics, poorer baseline renal function, and lower urine output (all P < .01). Randomized nesiritide treatment was not associated with diuretic response ( P = .987). Good diuretic response was independently associated with a significantly decreased risk of 30-day all-cause mortality or heart failure rehospitalization (odds ratio 0.44, 95% CI 0.29-0.65, highest vs lowest quintile, P < .001). Diuretic response based on urine output per 40 mg of furosemide showed similar results in terms of clinical predictors, association with outcome, and the absence of an effect of nesiritide. Conclusions Poor diuretic response early after hospital admission for AHF is associated with low blood pressure, renal impairment, low urine output, and an increased risk of death or rehospitalization early after discharge. Nesiritide had a neutral effect on diuretic response. [ABSTRACT FROM AUTHOR]

Abstract: Background: Patients with flow-limiting coronary stenoses exhibit elevated left ventricular end-diastolic pressure (LVEDP) and abnormal left ventricular (LV) relaxation. Objective: We investigated the relationship of extent and severity of coronary artery disease (CAD) by coronary CT angiography (CTA) to LVEDP and measures of LV diastolic dysfunction. Methods: We identified consecutive patients undergoing coronary CTA and transthoracic echocardiography who were assessed for diastolic function. CAD was evaluated on a per-patient, per-vessel, and per-segment basis for intraluminal diameter stenosis by using an 18-segment model (0 = none, 1 = 1%–49%, 2 = 50%–69%, and 3 = 70%–100%) and summed over segments to obtain overall coronary plaque burden (segment stenosis score [SSS]; maximum = 54). Transthoracic echocardiography evaluated mitral inflow E wave-to-A wave ratio, tissue Doppler early mitral annual tissue velocity axial excursion, stage of diastolic dysfunction, and LV dimensions and estimated LVEDP from the ratio of mitral inflow velocity to early mitral annular (medial) tissue velocity. Results: Four hundred seventy-eight patients (57% women; mean age, 57.9 ± 14.6 years; 24.9% prior CAD) comprised the study population. Increasing per-patient maximal coronary stenosis, number of vessels with obstructive stenosis, and SSS were associated with increased LVEDP. The prevalence of advanced diastolic dysfunction increased with greater number of obstructive vessels. In multivariable analyses, SSS was associated with increased LVEDP (0.8 mm Hg per tertile increase in SSS, 0.5–1.1; P < .001); reduced E′ axial excursion (−0.3; 95% confidence interval [CI], −0.5 to −0.1; P = .001), increased LV mass index (1.6 g/m2 per tertile increase in SSS; P = .04), and increased relative wall thickness (0.005; 95% CI, 0.004–0.009; P = .03), with consistent relationships persisting even among persons with per-patient maximal stenosis <50% and LV ejection fraction ≥55%. Conclusions: Extent and severity of obstructive as well as nonobstructive CAD by coronary CTA are associated with increased LVEDP and measures of diastolic dysfunction. [Copyright &y& Elsevier]