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Objectives: Systematic review and meta-analysis of randomized clinical trials (RCT) to compare procedural outcomes between radial access (RA) and femoral access (FA)., Background: Recent RCTs suggest RA for coronary angiography and percutaneous coronary intervention reduces bleeding complications, but controversy exists regarding other benefits and risks relative to FA., Methods: Searches of MEDLINE, EMBASE, CENTRAL, LILACS, and major conference abstracts identified relevant studies published from 1985-2016. We qualitatively evaluated study methodology and risk of bias. Quantitative data were abstracted relevant to the primary endpoints of major adverse cardiovascular events (MACE) and major bleeding (MB), and secondary outcomes including vascular complications and procedural failure., Results: We identified 2,098 titles, from which 48 studies with 29,446 patients met inclusion criteria for our analysis. We found there was a significant reduction of MACE with RA versus FA (RR 0.86, 95% CI 0.77-0.95, I 2  = 0%), driven by a reduction in death, but not MI or stroke. MB occurred less frequently with RA (RR 0.54, 95% CI 0.44-0.67, I 2  = 4%). Vascular complications were also reduced with RA (RR 0.39, 95% CI 0.25-0.59, I 2  = 75%), while procedural failure was more common (RR 2.15, 95% CI 1.65-2.82, I 2  = 53%), although there was significant statistical heterogeneity for both of these outcomes. Most studies demonstrated low risk of selection and attrition biases, but high risk of detection bias., Conclusions: Radial access reduces the risk of death, major bleeding, and vascular complications as compared to femoral access but increases the risk of procedural failure. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Women have higher mortality rates than men after coronary angioplasty. Differences in target vessel size may partially account for these differences. We set out to explore the effects of sex, body surface area (BSA), and target coronary vessel size on clinical outcomes after angioplasty., Methods: Data from 5 interventional trials and 1 registry were pooled for analysis (n = 3982)., Results: Compared with men, women undergoing angioplasty were older, had lower weights and BSA, more coronary risk factors, and slightly smaller target coronary vessel size (as assessed by reference vessel diameter). The correlation between target vessel size and BSA was poor (r = 0.13). At 6 months, women had higher mortality rates (1.7% vs 0.8%, P =.03) but similar rates of myocardial infarction and repeat revascularization. On univariate analysis, advanced age, smaller BSA, and female sex were associated with increased mortality, but target vessel size was not. Advanced age was the only significant multivariate predictor of mortality. Target vessel size and diabetes were independent predictors of repeat revascularization., Conclusions: Women have higher unadjusted 6-month mortality rates after angioplasty, owing largely to their more advanced age at the time of intervention. Smaller target vessel size is associated with increased risk of restenosis and repeat revascularization; however, it does not appear to be a predictor for downstream mortality. As such, the fact that women have smaller vessels does not account for their higher 6-month mortality after coronary angioplasty.

The article presents a study which examined the diagnostic efficiency of 320-row detector computed tomography (CT) in detecting coronary artery luminal stenosis and its corresponding myocardial perfusion deficits in patients with suspected coronary artery disease. The method is compared with the gold standard of traditional coronary angiography and single-photon emission CT myocardial perfusion imaging. The aim of the study is to develop a new left ventricular segmentation model.

The article evaluates the accuracy of 320-row computed tomography perfusion imaging (CTP) to detect atherosclerosis causing myocardial ischemia. The study involved 50 symptomatic patients who underwent myocardial perfusion imaging (MPI) and 320 CTP imaging. The study concluded that CTP imaging with rest and adenosine stress 320-row CT is accurate in detecting obstructive atherosclerosis causing myocardial ischemia.

Abstract: Multidetector coronary computed tomography angiography (CTA) is a promising modality for widespread clinical application because of its noninvasive nature and high diagnostic accuracy as found in previous studies using 64 to 320 simultaneous detector rows. It is, however, limited in its ability to detect myocardial ischemia. In this article, we describe the design of the CORE320 study (“Combined coronary atherosclerosis and myocardial perfusion evaluation using 320 detector row computed tomography”). This prospective, multicenter, multinational study is unique in that it is designed to assess the diagnostic performance of combined 320-row CTA and myocardial CT perfusion imaging (CTP) in comparison with the combination of invasive coronary angiography and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). The trial is being performed at 16 medical centers located in 8 countries worldwide. CT has the potential to assess both anatomy and physiology in a single imaging session. The co-primary aim of the CORE320 study is to define the per-patient diagnostic accuracy of the combination of coronary CTA and myocardial CTP to detect physiologically significant coronary artery disease compared with (1) the combination of conventional coronary angiography and SPECT-MPI and (2) conventional coronary angiography alone. If successful, the technology could revolutionize the management of patients with symptomatic CAD. [Copyright &y& Elsevier]

Objectives: This study was designed to evaluate whether the absence of coronary calcium could rule out ≥50% coronary stenosis or the need for revascularization. Background: The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients. Methods: A substudy was made of the CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors) multicenter trial comparing the diagnostic performance of 64-detector computed tomography to conventional angiography. Patients clinically referred for conventional angiography were asked to undergo a CS scan up to 30 days before. Results: In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 ± 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of ≥50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 ≥50% stenosis. The overall sensitivity for CS = 0 to predict the absence of ≥50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with ≥50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium. Conclusions: The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients with high enough suspicion of coronary artery disease to be referred for coronary angiography, in contrast with the published recommendations. Total coronary occlusion frequently occurs in the absence of any detectable calcification. (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]; NCT00738218) [Copyright &y& Elsevier]

The article presents a multicenter study which examined the accuracy of 64-row, 0.5-mm multidetector computed tomographic (CT) angiography in comparison to conventional coronary angiography in patients with suspected coronary artery disease. CT and conventional angiography were used to analyze patients with calcium scores of 600 or less. 50% or more stenosis was classified as clinically significant. The Duke Coronary Artery Disease Index was used to assess disease severity. The presence and severity of obstructive coronary artery disease and subsequent revascularization in symptomatic patients was accurately identified with multidetector CT angiography. The positive and negative predictive values show that multidetector CT angiography cannot replace conventional coronary angiography.

Invasive coronary angiography remains the standard for assessment of coronary anatomy and pathology, and for determining the extent and severity of coronary lumen obstruction in coronary artery disease. Recent advances in multidetector row computed tomography (MDCT) technology allowing noninvasive imaging of the coronary arteries has led to widespread enthusiasm for the use of noninvasive coronary angiography. A comprehensive and clinically useful MDCT study should incorporate an understanding of the patient history and reason for performance of the test, an overall assessment of study quality, and a complete description of pertinent findings. Because the majority of cardiac computed tomography (CT) studies are now being performed for the evaluation of the coronary arteries and obstructive coronary disease, a clear understanding of what the clinician wants to know from a CTA is critical to its comprehensive interpretation. In this manuscript, we provide an overview of the necessary components of CT coronary angiogram interpretation, from the point of view of the practicing invasive cardiologist. [ABSTRACT FROM AUTHOR]

The article focuses on whether genetic variation at the locus encoding hypoxia-inducible factor 1α (HIF-lα) influences collateral formation in patients with coronary artery disease. Collateral formation is highly variable between patients and only partially attributable to differences in the degree of the coronary artery occlusive disease. Several factors associated with decreased collateral formation have been described in animals and humans, including aging, hypercholesterolemia, hypertension and cigarette smoking.

Background Myocardial CT perfusion (CTP) has been validated as an incremental diagnostic predictor over coronary computed tomography angiography (CTA) in assessing hemodynamically significant stenosis. Objectives To assess the diagnostic performance of CTA and CTP alone versus combined CTA–CTP stratified by Morise's pre-test probability and coronary artery calcium (CAC, Agatston) score. Methods 381 individuals (153 low/intermediate-risk for CAD, 83 high-risk, 145 known CAD) were further stratified based on CAC score cut-offs of 1–399 and ≥ 400. Area under the curve for receiver operating characteristics (AUC) was calculated to assess the diagnostic performance. Reference standards were QCA ≥ 50% stenosis + corresponding SPECT summed stress score ≥ 1. Results In both pre-test risk groups with an Agatston score of 1–399, AUCs of CTA–CTP were not significantly different than that from CTA alone. In the low/intermediate-risk group with CAC score 1–399, AUC for CTA–CTP (89) was higher than that for CTP (76, p = 0.003) alone. In the same group with CAC score ≥ 400, AUCs were higher for CTA–CTP (97) than that for CTA (88, p = 0.030) and CTP (83, p = 0.033). In high risk/known CAD patients with CAC 1–399, diagnostic performance for CTA–CTP (77) was superior to CTP (71, p = 0.037) alone. In the high risk/known CAD group with CAC score ≥ 400, AUCs for combined imaging were higher (86) than that for CTA (75, p < 0.001) as well as CTP (78, p = 0.020). Conclusions The incremental diagnostic accuracy of CTP over CTA persists in patients across severity spectra of pre-test probability of CAD and coronary artery calcification. In patients with severe coronary calcification (CAC score ≥ 400), combined CTA–CTP has better diagnostic accuracy than CTA and CTP alone. [ABSTRACT FROM AUTHOR]

Coronary vessel distensibility is reduced with atherosclerosis and normal aging, but direct measurements have historically required invasive measurements at cardiac catheterization. Therefore, we sought to assess coronary artery distensibility noninvasively using 3.0 Telsa coronary magnetic resonance imaging (MRI) and to test the hypothesis that this noninvasive technique can detect differences in coronary distensibility between healthy subjects and those with coronary artery disease (CAD). A total of 38 healthy, adult subjects (23 men, mean age 31 ± 10 years) and 21 patients with CAD, diagnosed using x-ray angiography (11 men, mean age 57 ± 6 years) were studied using a commercial whole-body MRI system. In each subject, the proximal segment of a coronary artery was imaged for the cross-sectional area measurements using cine spiral MRI. The distensibility (mm Hg−1 × 103) was determined as (end-systolic lumen area − end-diastolic lumen area)/(pulse pressure × end-diastolic lumen area). The pulse pressure was calculated as the difference between the systolic and diastolic brachial blood pressure. A total of 34 healthy subjects and 19 patients had adequate image quality for coronary area measurements. Coronary artery distensibility was significantly greater in the healthy subjects than in those with CAD (mean ± SD 2.4 ± 1.7 mm Hg−1 × 103 vs 1.1 ± 1.1 mm Hg−1 × 103, respectively, p = 0.007; median 2.2 vs 0.9 mm Hg−1 × 103). In a subgroup of 10 patients with CAD, we found a significant correlation between the coronary artery distensibility measurements assessed using MRI and x-ray coronary angiography (R = 0.65, p = 0.003). In a group of 10 healthy subjects, the repeated distensibility measurements demonstrated a significant correlation (R = 0.80, p = 0.006). In conclusion, 3.0-Tesla MRI, a reproducible noninvasive method to assess human coronary artery vessel wall distensibility, is able to detect significant differences in distensibility between healthy subjects and those with CAD. [Copyright &y& Elsevier]