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2. Comprehensive clinical assessment identifies specific neurocognitive deficits in working-age patients with long-COVID.

Author

David A Holdsworth, Rebecca Chamley, Rob Barker-Davies, Oliver O'Sullivan, Peter Ladlow, James L Mitchell, Dominic Dewson, Daniel Mills, Samantha L J May, Mark Cranley, Cheng Xie, Edward Sellon, Joseph Mulae, Jon Naylor, Betty Raman, Nick P Talbot, Oliver J Rider, Alexander N Bennett, and Edward D Nicol

Subjects
Medicine, Science
Abstract

IntroductionThere have been more than 425 million COVID-19 infections worldwide. Post-COVID illness has become a common, disabling complication of this infection. Therefore, it presents a significant challenge to global public health and economic activity.MethodsComprehensive clinical assessment (symptoms, WHO performance status, cognitive testing, CPET, lung function, high-resolution CT chest, CT pulmonary angiogram and cardiac MRI) of previously well, working-age adults in full-time employment was conducted to identify physical and neurocognitive deficits in those with severe or prolonged COVID-19 illness.Results205 consecutive patients, age 39 (IQR30.0-46.7) years, 84% male, were assessed 24 (IQR17.1-34.0) weeks after acute illness. 69% reported ≥3 ongoing symptoms. Shortness of breath (61%), fatigue (54%) and cognitive problems (47%) were the most frequent symptoms, 17% met criteria for anxiety and 24% depression. 67% remained below pre-COVID performance status at 24 weeks. One third of lung function tests were abnormal, (reduced lung volume and transfer factor, and obstructive spirometry). HRCT lung was clinically indicated in ConclusionDespite low rates of residual cardiopulmonary pathology, in this cohort, with low rates of premorbid illness, there is a high burden of symptoms and failure to regain pre-COVID performance 6-months after acute illness. Cognitive assessment identified a specific deficit of the same magnitude as intoxication at the UK drink driving limit or the deterioration expected with 10 years ageing, which appears to contribute significantly to the symptomatology of long-COVID.

Published
2022
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3. National Trends in Coronary Artery Disease Imaging

Author

Jonathan R. Weir-McCall, Michelle C. Williams, Anoop S.V. Shah, Giles Roditi, James H.F. Rudd, David E. Newby, and Edward D. Nicol

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Published
2023

4. Cardiac MRI improves cardiovascular risk stratification in hazardous occupations

Author

David A. Holdsworth, Iain T. Parsons, Rebecca Chamley, Joseph Britton, Christopher Pavitt, A. John Baksi, Stefan Neubauer, Joanna d’Arcy, and Edward D. Nicol

Subjects
Occupational, Risk, Aviation medicine, Ectopy, Cardiomyopathy, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract Background The benefit of cardiovascular magnetic resonance Imaging (CMR) in assessing occupational risk is unknown. Pilots undergo frequent medical assessment for occult disease, which threatens incapacitation or distraction during flight. ECG and examination anomalies often lead to lengthy restriction, pending full investigation. CMR provides a sensitive, specific assessment of cardiac anatomy, tissue characterisation, perfusion defects and myocardial viability. We sought to determine if CMR, when added to standard care, would alter occupational outcome. Methods A retrospective review was conducted of all personnel attending the RAF Aviation Medicine Consultation Service (AMCS) for assessment of a cardiac anomaly, over a 2-year period. Those undergoing standard of care (history, examination, exercise ECG, 24 h-Holter and transthoracic echocardiography), and those undergoing a CMR in addition, were identified. The influence of CMR upon the final decision regarding flying restriction was determined by comparing the diagnosis reached with standard of care plus CMR vs. standard of care alone. Results Of the ~ 8000 UK military aircrew, 558 personnel were seen for cardiovascular assessment. Fifty-two underwent CMR. A normal TTE did not reliably exclude abnormalities subsequently detected by CMR. Addition of CMR resulted in an upgraded occupational status in 62% of those investigated, with 37% returning to unrestricted duties. Only 8% of referrals were undiagnosed following CMR. All these were cases of borderline chamber dilatation and reduction in systolic function in whom diagnostic uncertainty remained between physiological exercise adaptation and early cardiomyopathy. Conclusions CMR increases the likelihood of a definitive diagnosis and of return to flying. This study supports early use of CMR in occupational assessment for high-hazard occupations.

Published
2019
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5. Aeromedical Transfer of Patients with Viral Hemorrhagic Fever

Author

Edward D. Nicol, Stephen Mepham, Jonathan Naylor, Ian Mollan, Matthew Adam, Joanna d’Arcy, Philip Gillen, Emma Vincent, Belinda Mollan, David Mulvaney, Andrew Green, and Michael Jacobs

Subjects
hemorrhagic fever, viruses, Ebola virus, infection control, patient transfer, patient isolation, Medicine, Infectious and parasitic diseases, RC109-216
Abstract

For >40 years, the British Royal Air Force has maintained an aeromedical evacuation facility, the Deployable Air Isolator Team (DAIT), to transport patients with possible or confirmed highly infectious diseases to the United Kingdom. Since 2012, the DAIT, a joint Department of Health and Ministry of Defence asset, has successfully transferred 1 case-patient with Crimean-Congo hemorrhagic fever, 5 case-patients with Ebola virus disease, and 5 case-patients with high-risk Ebola virus exposure. Currently, no UK-published guidelines exist on how to transfer such patients. Here we describe the DAIT procedures from collection at point of illness or exposure to delivery into a dedicated specialist center. We provide illustrations of the challenges faced and, where appropriate, the enhancements made to the process over time.

Published
2019
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6. Exercise tolerance, fatigue, mental health, and employment status at 5 and 12 months following COVID-19 illness in a physically trained population

Author

Peter Ladlow, David A. Holdsworth, Oliver O’Sullivan, Robert M. Barker-Davies, Andrew Houston, Rebecca Chamley, Kasha Rogers-Smith, Victoria Kinkaid, Adam Kedzierski, Jon Naylor, Joseph Mulae, Mark Cranley, Edward D. Nicol, and Alexander N. Bennett

Subjects
Physiology, Physiology (medical)
Abstract

Subjective exercise limiting symptoms such as fatigue and shortness of breath reduce but remain prevalent in symptomatic groups. At 12 mo, COVID-19-exposed individuals still have a reduced capacity for work at the anaerobic threshold (which best predicts sustainable intensity), despite oxygen uptake comparable to controls. The prevalence of COVID-19-exposed individuals considered “medically non-deployable” remains high at 47%.

Published
2023

7. Survival After Invasive or Conservative Management of Stable Coronary Disease

Author

Judith S. Hochman, Rebecca Anthopolos, Harmony R. Reynolds, Sripal Bangalore, Yifan Xu, Sean M. O’Brien, Stavroula Mavromichalis, Michelle Chang, Aira Contreras, Yves Rosenberg, Ruth Kirby, Balram Bhargava, Roxy Senior, Ann Banfield, Shaun G. Goodman, Renato D. Lopes, Radosław Pracoń, José López-Sendón, Aldo Pietro Maggioni, Jonathan D. Newman, Jeffrey S. Berger, Mandeep S. Sidhu, Harvey D. White, Andrea B. Troxel, Robert A. Harrington, William E. Boden, Gregg W. Stone, Daniel B. Mark, John A. Spertus, David J. Maron, Shari Esquenazi-Karonika, Margaret Gilsenan, Ewelina Gwiszcz, Patenne Mathews, Samaa Mohamed, Anna Naumova, Arline Roberts, Kerrie VanLoo, Ying Lu, Zhen Huang, Samuel Broderick, Luis Guzmán, Joseph Selvanayagam, Gabriel Steg, Jean-Michel Juliard, Rolf Doerr, Matyas Keltai, Boban Thomas, Tali Sharir, Eugenia Nikolsky, Aldo P. Maggioni, Shun Kohsaka, Jorge Escobedo, Olga Bockeria, Claes Held, Leslee J. Shaw, Lawrence Phillips, Daniel Berman, Raymond Y. Kwong, Michael H. Picard, Bernard R. Chaitman, Ziad Ali, James Min, G.B. John Mancini, Jonathon Leipsic, Graham Hillis, Suku Thambar, Majo Joseph, John Beltrame, Irene Lang, Herwig Schuchlenz, Kurt Huber, Kaatje Goetschalckx, Whady Hueb, Paulo Ricardo Caramori, Alexandre de Quadros, Paola Smanio, Claudio Mesquita, João Vitola, José Marin-Neto, Expedito Ribeiro da Silva, Rogério Tumelero, Marianna Andrade, Alvaro Rabelo Alves, Frederico Dall’Orto, Carisi Polanczyk, Estevão Figueiredo, Andrew Howarth, Gilbert Gosselin, Asim Cheema, Kevin Bainey, Denis Phaneuf, Ariel Diaz, Pallav Garg, Shamir Mehta, Graham Wong, Andy Lam, James Cha, Paul Galiwango, Amar Uxa, Benjamin (Ben) Chow, Adnan Hameed, Jacob Udell, Magdy Hamid, Marie Hauguel-Moreau, Alain Furber, Pascal Goube, Philippe-Gabriel Steg, Gilles Barone-Rochette, Christophe Thuaire, Michel Slama, Georg Nickenig, Raffi Bekeredjian, P. Christian Schulze, Bela Merkely, Geza Fontos, András Vértes, Albert Varga, Ajit Kumar, Rajesh G. Nair, Purvez Grant, Cholenahally Manjunath, Nagaraja Moorthy, Santhosh Satheesh, Ranjit Kumar Nath, Gurpreet Wander, Johann Christopher, Sudhanshu Dwivedi, Abraham Oomman, Atul Mathur, Milind Gadkari, Sudhir Naik, Eapen Punnoose, Ranjan Kachru, Upendra Kaul, Arthur Kerner, Giuseppe Tarantini, Gian Piero Perna, Emanuela Racca, Andrea Mortara, Lorenzo Monti, Carlo Briguori, Gianpiero Leone, Roberto Amati, Mauro Salvatori, Antonio Di Chiara, Paolo Calabro, Marcello Galvani, Stefano Provasoli, Keiichi Fukuda, Shintaro Nakano, Aleksandras Laucevicius, Sasko Kedev, Ahmad Khairuddin, Robert Riezebos, Jorik Timmer, Spencer Heald, Ralph Stewart, Walter Mogrovejo Ramos, Marcin Demkow, Tomasz Mazurek, Jarozlaw Drozdz, Hanna Szwed, Adam Witkowski, Nuno Ferreira, Fausto Pinto, Ruben Ramos, Bogdan Popescu, Calin Pop, Leo Bockeria, Elena Demchenko, Alexander Romanov, Leonid Bershtein, Ahmed Jizeeri, Goran Stankovic, Svetlana Apostolovic, Nada Cemerlic Adjic, Marija Zdravkovic, Branko Beleslin, Milica Dekleva, Goran Davidovic, Terrance Chua, David Foo, Kian Keong Poh, Mpiko Ntsekhe, Alessandro Sionis, Francisco Marin, Vicente Miró, Montserrat Gracida Blancas, José González-Juanatey, Francisco Fernández-Avilés, Jesús Peteiro, Jose Enrique Castillo Luena, Johannes Aspberg, Mariagrazia Rossi, Srun Kuanprasert, Sukit Yamwong, Nicola Johnston, Patrick Donnelly, Andrew Moriarty, Ahmed Elghamaz, Sothinathan Gurunathan, Nikolaos Karogiannis, Benoy N. Shah, Richard H.J. Trimlett, Michael B. Rubens, Edward D. Nicol, Tarun K. Mittal, Reinette Hampson, Reto Gamma, Mark De Belder, Thuraia Nageh, Steven Lindsay, Kreton Mavromatis, Todd Miller, Subhash Banerjee, Harmony Reynolds, Khaled Nour, and Peter Stone

Subjects
Physiology (medical), Cardiology and Cardiovascular Medicine
Abstract

Background: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. Methods: ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. Results: Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85–1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63–0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08–1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. Conclusions: There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04894877.

Published
2023

8. Conflicts of interest in electrophysiology and devices presentations

Author

C F Camm, W Crawford, I Prachee, J Olivarius-McAllister, A Schaefer, Z Raouf, A Bello, M Ginks, and E D Nicol

Subjects
Physiology (medical), Cardiology and Cardiovascular Medicine
Abstract

AimsIndustry collaboration with arrhythmia and devices research is common. However, this results in conflicts of interest (CoI) for researchers that should be disclosed. This study aimed to examine the quality of CoI disclosures in arrhythmia and devices presentations.MethodsRecorded presentations from the Arrhythmia & Devices section of the ESC Annual Congress 2016–2020 were assessed. The number of words, conflicts, and time displayed was documented for CoI declarations. Meta-data including sponsorship by an industry partner, presenter sex, and institution were obtained.ResultsOf 1153 presentations assessed, 999 were suitable for inclusion. CoI statements were missing from 7.2% of presentations, and 58% reported ≥1 conflict. Those with conflicts spent less time-per-word on their disclosures (median 150 ms, interquartile range [IQR] 83–273 ms) compared with those without conflicts (median 250 ms, IQR 125–375 ms). One-in-eight presentations were sponsored (12.8%, n = 128). CoI statements were more likely to be missing in sponsored presentations (14.8%, n = 19) compared with non-sponsored presentations (6.1%, n = 53), P = 0.0003. Sponsored presentations contained a greater median number of CoIs (10, IQR 6–18) compared with non-sponsored sessions (1, IQR 0–5), P < 0.0001. Time-per-word spent on COI disclosures was 50% lower in sponsored sessions (125 ms, IQR 75–231 ms) compared with non-sponsored sessions (250 ms, IQR 125–375 ms), P < 0.0001.ConclusionThe majority of those presenting arrhythmia and devices research have CoIs to declare. Declarations were often missing or displayed for short periods of time. Presenters in sponsored sessions, while being more conflicted, had a lower standard of declaration suggesting a higher risk of potential bias which viewers had insufficient opportunity to assess.

Published
2022

10. Exercise ECG for Screening in Military Aircrew

Author

Norbert Guettler, Edward D. Nicol, and Stefan Sammito

Subjects
Electrocardiography, Military Personnel, Aerospace Medicine, Exercise Test, Humans, Coronary Artery Disease, General Medicine
Abstract

INTRODUCTION: The exercise electrocardiogram (ExECG), or stress test, is a widely used screening tool in occupational medicine designed to detect occult coronary artery disease, and assess performance capacity and cardiovascular fitness. In some guidelines, it is recommended for high-risk occupations in which occult disease could possibly endanger public safety. In aviation medicine, however, there is an ongoing debate on the use and periodicity of ExECG for screening of aircrew.METHOD: In the German Armed Forces, aircrew applicants and active-duty aircrew undergo screening ExECG. We analyzed 7646 applicant ExECGs (5871 from pilot and 1775 from nonpilot applicants) and 17,131 ExECGs from 3817 active-duty pilots. All were performed at the German Air Force Centre of Aerospace Medicine (GAFCAM) and analyzed for ECG abnormalities, performance capacity, blood pressure, and heart rate response.RESULTS: Only 15/5871 (0.2%) of pilot applicants required further investigation and none were ultimately disqualified for aircrew duties due to their ExECG results. Of the nonpilot applicants, 22/1775 (1.2%) required further diagnostic work-up due to their ExECG findings, with only 1 ultimately disqualified. From active-duty pilots, 84/17,131 (0.5%) ExECGs revealed findings requiring further investigation, with only 2 pilots ultimately disqualified from flying duties.DISCUSSION: The extremely low yield of ExECG findings requiring further evaluation and/or disqualification for aircrew duties suggest its use is questionable and not cost-effective as a screening tool in this cohort. It may be enough to perform ExECG on clinical indication alone.Guettler N, Nicol ED, Sammito S. Exercise ECG for screening in military aircrew. Aerosp Med Hum Perform. 2022; 93(9):666–672.

Published
2022

11. The effect of medium-term recovery status after COVID-19 illness on cardiopulmonary exercise capacity in a physically active adult population

Author

Peter Ladlow, Oliver O’Sullivan, Alexander N. Bennett, Robert Barker-Davies, Andrew Houston, Rebecca Chamley, Samantha May, Daniel Mills, Dominic Dewson, Kasha Rogers-Smith, Christopher Ward, John Taylor, Joseph Mulae, Jon Naylor, Edward D. Nicol, and David A. Holdsworth

Subjects
Adult, Heart Failure, Oxygen, Exercise Tolerance, Oxygen Consumption, Physiology, Physiology (medical), Exercise Test, COVID-19, Humans
Abstract

A failure to fully recover following coronavirus disease 2019 (COVID-19) may have a profound impact on high-functioning populations ranging from frontline emergency services to professional or amateur/recreational athletes. The aim of the study is to describe the medium-term cardiopulmonary exercise profiles of individuals with "persistent symptoms" and individuals who feel "recovered" after hospitalization or mild-moderate community infection following COVID-19 to an age, sex, and job-role matched control group. A total of 113 participants underwent cardiopulmonary functional tests at a mean of 159 ± 7 days (∼5 mo) following acute illness; 27 hospitalized with persistent symptoms (hospitalized-symptomatic), 8 hospitalized and now recovered (hospitalized-recovered); 34 community managed with persistent symptoms (community-symptomatic); 18 community managed and now recovered (community-recovered); and 26 controls. Hospitalized groups had the least favorable body composition (body mass, body mass index, and waist circumference) compared with controls. Hospitalized-symptomatic and community-symptomatic individuals had a lower oxygen uptake (V̇o

Published
2022

12. Factors influencing medium- and long-term occupational impact following COVID-19

Author

O O’Sullivan, A Houston, P Ladlow, R M Barker-Davies, R Chamley, A N Bennett, E D Nicol, and D A Holdsworth

Subjects
Public Health, Environmental and Occupational Health
Abstract

Background Significant numbers of individuals struggle to return to work following acute coronavirus disease 2019 (COVID-19). The UK Military developed an integrated medical and occupational pathway (Defence COVID-19 Recovery Service, DCRS) to ensure safe return to work for those with initially severe disease or persistent COVID-19 sequalae. Medical deployment status (MDS) is used to determine ability to perform job role without restriction (‘fully deployable’, FD) or with limitations (‘medically downgraded’, MDG). Aims To identify which variables differ between those who are FD and MDG 6 months after acute COVID-19. Within the downgraded cohort, a secondary aim is to understand which early factors are associated with persistent downgrading at 12 and 18 months. Methods Individuals undergoing DCRS had comprehensive clinical assessment. Following this, their electronic medical records were reviewed and MDS extracted at 6, 12 and 18 months. Fifty-seven predictors taken from DCRS were analysed. Associations were sought between initial and prolonged MDG. Results Three hundred and twenty-five participants were screened, with 222 included in the initial analysis. Those who were initially downgraded were more likely to have post-acute shortness of breath (SoB), fatigue and exercise intolerance (objective and subjective), cognitive impairment and report mental health symptoms. The presence of fatigue and SoB, cognitive impairment and mental health symptoms was associated with MDG at 12 months, and the latter two, at 18 months. There were also modest associations between cardiopulmonary function and sustained downgrading. Conclusions Understanding the factors that are associated with initial and sustained inability to return to work allows individualized, targeted interventions to be utilized.

Published
2023

14. The Use and Efficacy of FFR-CT

Author

Tarun K. Mittal, Sandeep S. Hothi, Vinod Venugopal, John Taleyratne, David O’Brien, Kazi Adnan, Joban Sehmi, Georgios Daskalopoulos, Aparna Deshpande, Sara Elfawal, Vinoda Sharma, Rajai A. Shahin, Mengshi Yuan, Dominik Schlosshan, Andrew Walker, Saif-El-Dean Abdel Rahman, Imran Sunderji, Sidhesh Wagh, Jocelyn Chow, Mohammed Masood, Sumeet Sharma, Sharad Agrawal, Chary Duraikannu, Elisa McAlindon, Saeed Mirsadraee, Edward D. Nicol, and Andrew D. Kelion

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Published
2023

15. Computed tomographic angiography in coronary artery disease

Author

Patrick W. Serruys, Nozomi Kotoku, Bjarne L. Nørgaard, Scot Garg, Koen Nieman, Marc R. Dweck, Jeroen J. Bax, Juhani Knuuti, Jagat Narula, Divaka Perera, Charles A. Taylor, Jonathon A. Leipsic, Edward D. Nicol, Nicolo Piazza, Carl J. Schultz, Kakuya Kitagawa, Bernard De Bruyne, Carlos Collet, Kaoru Tanaka, Saima Mushtaq, Marta Belmonte, Darius Dudek, Adriana Zlahoda-Huzior, Shengxian Tu, William Wijns, Faisal Sharif, Matthew J. Budoff, Johan de Mey, Daniele Andreini, and Yoshinobu Onuma

Subjects
Fractional Flow Reserve, Myocardial, Coronary Angiography/methods, Computed Tomography Angiography/methods, Predictive Value of Tests, Tomography, X-Ray Computed/methods, Coronary Stenosis, Humans, Coronary Vessels/diagnostic imaging, Plaque, Atherosclerotic/diagnostic imaging, Coronary Artery Disease/diagnosis, Cardiology and Cardiovascular Medicine
Abstract

Coronary computed tomographic angiography (CCTA) is becoming the first-line investigation for establishing the presence of coronary artery disease and, with fractional flow reserve (FFRCT), its haemodynamic significance. In patients without significant epicardial obstruction, its role is either to rule out atherosclerosis or to detect subclinical plaque that should be monitored for plaque progression/regression following prevention therapy and provide risk classification. Ischaemic non-obstructive coronary arteries are also expected to be assessed by non-invasive imaging, including CCTA. In patients with significant epicardial obstruction, CCTA can assist in planning revascularisation by determining the disease complexity, vessel size, lesion length and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g., rotational atherectomy) and in determining the best landing zone for stents or bypass grafts.

Published
2023

16. Contemporary cardiovascular computed tomography (CCT) training: Serial surveys of the international CCT community by the Fellow and Resident Leaders of the Society of Cardiovascular Computed Tomography (SCCT) Committee (FiRST) and SCCT Future Leaders Program (FLP)

Author

Nidhi Madan, David J. Hur, Michael P. Gannon, Sumit Gupta, Jonathan R. Weir-McCall, Claire Johns, Arnav Kumar, Prashant Nagpal, Emilio Fentanes, James Lee, Andrew D. Choi, Maros Ferencik, Christopher D. Maroules, Todd C. Villines, and Edward D. Nicol

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Published
2023

17. Cardiopulmonary, Functional, Cognitive and Mental Health Outcomes Post-COVID-19, Across the Range of Severity of Acute Illness, in a Physically Active, Working-Age Population

Author

Oliver O’Sullivan, David A. Holdsworth, Peter Ladlow, Robert M. Barker-Davies, Rebecca Chamley, Andrew Houston, Samantha May, Dominic Dewson, Daniel Mills, Kayleigh Pierce, James Mitchell, Cheng Xie, Edward Sellon, Jon Naylor, Joseph Mulae, Mark Cranley, Nick P. Talbot, Oliver J. Rider, Edward D. Nicol, and Alexander N. Bennett

Subjects
Physical Therapy, Sports Therapy and Rehabilitation, Orthopedics and Sports Medicine
Abstract

Background The COVID-19 pandemic has led to significant morbidity and mortality, with the former impacting and limiting individuals requiring high physical fitness, including sportspeople and emergency services. Methods Observational cohort study of 4 groups: hospitalised, community illness with on-going symptoms (community-symptomatic), community illness now recovered (community-recovered) and comparison. A total of 113 participants (aged 39 ± 9, 86% male) were recruited: hospitalised (n = 35), community-symptomatic (n = 34), community-recovered (n = 18) and comparison (n = 26), approximately five months following acute illness. Participant outcome measures included cardiopulmonary imaging, submaximal and maximal exercise testing, pulmonary function, cognitive assessment, blood tests and questionnaires on mental health and function. Results Hospitalised and community-symptomatic groups were older (43 ± 9 and 37 ± 10, P = 0.003), with a higher body mass index (31 ± 4 and 29 ± 4, P 2 slope, 29.6 ± 5.1, P P P P = 0.004). Clinically significant abnormal cardiopulmonary imaging findings were present in 6% of hospitalised participants. Community-recovered individuals had no significant differences in outcomes to the comparison group. Conclusion Symptomatically recovered individuals who suffered mild-moderate acute COVID-19 do not differ from an age-, sex- and job-role-matched comparison population five months post-illness. Individuals who were hospitalised or continue to suffer symptoms may require a specific comprehensive assessment prior to return to full physical activity.

Published
2023

18. Deep-Learning for Epicardial Adipose Tissue Assessment With Computed Tomography

Author

Henry W. West, Muhammad Siddique, Michelle C. Williams, Lucrezia Volpe, Ria Desai, Maria Lyasheva, Sheena Thomas, Katerina Dangas, Christos P. Kotanidis, Pete Tomlins, Ciara Mahon, Attila Kardos, David Adlam, John Graby, Jonathan C.L. Rodrigues, Cheerag Shirodaria, John Deanfield, Nehal N. Mehta, Stefan Neubauer, Keith M. Channon, Milind Y. Desai, Edward D. Nicol, David E. Newby, and Charalambos Antoniades

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Published
2023

19. Dysautonomia following COVID-19 is not associated with subjective limitations or symptoms but is associated with objective functional limitations

Author

Peter Ladlow, Oliver O’Sullivan, Andrew Houston, Robert Barker-Davies, Samantha May, Daniel Mills, Dominic Dewson, Rebecca Chamley, Jon Naylor, Joseph Mulae, Alexander N. Bennett, Edward D. Nicol, and David A. Holdsworth

Subjects
Heart Failure, Oxygen Consumption, Physiology (medical), Exercise Test, COVID-19, Humans, Primary Dysautonomias, Cardiology and Cardiovascular Medicine, Exercise, Article
Abstract

Individuals who contract coronavirus disease 2019 (COVID-19) can suffer with persistent and debilitating symptoms long after the initial acute illness. Heart rate (HR) profiles determined during cardiopulmonary exercise testing (CPET) and delivered as part of a post-COVID recovery service may provide insight into the presence and impact of dysautonomia on functional ability.Using an active, working-age, post-COVID-19 population, the purpose of this study was to (1) determine and characterize any association between subjective symptoms and dysautonomia; and (2) identify objective exercise capacity differences between patients classified "with" and those "without" dysautonomia.Patients referred to a post-COVID-19 service underwent comprehensive clinical assessment, including self-reported symptoms, CPET, and secondary care investigations when indicated. Resting HR75 bpm, HR increase with exercise89 bpm, and HR recovery25 bpm 1 minute after exercise were used to define dysautonomia. Anonymized data were analyzed and associations with symptoms, and CPET outcomes were determined.Fifty-one of the 205 patients (25%) reviewed as part of this service evaluation had dysautonomia. There were no associations between symptoms or perceived functional limitation and dysautonomia (P.05). Patients with dysautonomia demonstrated objective functional limitations with significantly reduced work rate (219 ± 37 W vs 253 ± 52 W; P.001) and peak oxygen consumption (V̇oDysautonomia is associated with objective functional limitations but is not associated with subjective symptoms or limitation.

Published
2022

20. Cardiopulmonary assessment prior to returning to high-hazard occupations post-symptomatic COVID-19 infection: a position statement of the Aviation and Occupational Cardiology Task Force of the European Association of Preventive Cardiology

Author

Rienk Rienks, David Holdsworth, Constantinos H Davos, Martin Halle, Alexander Bennett, Gianfranco Parati, Norbert Guettler, and Edward D Nicol

Subjects
Post-Acute COVID-19 Syndrome, SARS-CoV-2, Epidemiology, Cardiology, Humans, COVID-19, Occupations, Aviation, Cardiology and Cardiovascular Medicine
Abstract

This article provides an overview of the recommendations of the Aviation and Occupational Cardiology Task Force of the European Association of Preventive Cardiology on returning individuals to work in high-hazard occupations (such as flying, diving, and workplaces that are remote from healthcare facilities) following symptomatic Coronavirus Disease 2019 (COVID-19) infection. This process requires exclusion of significant underlying cardiopulmonary disease and this consensus statement (from experts across the field) outlines the appropriate screening and investigative processes that should be undertaken. The recommended response is based on simple screening in primary healthcare to determine those at risk, followed by first line investigations, including an exercise capacity assessment, to identify the small proportion of individuals who may have circulatory, pulmonary, or mixed disease. These individuals can then receive more advanced, targeted investigations. This statement provides a pragmatic, evidence-based approach for those (in all occupations) to assess employee health and capacity prior to a return to work following severe disease, or while continuing to experience significant post-COVID-19 symptoms (so-called ‘long-COVID’ or post-COVID-19 syndrome).

Published
2022

21. Highlights of the 16th annual scientific meeting of the society of cardiovascular computed tomography

Author

Michelle C. Williams, Koen Nieman, Maros Ferencik, Kelley R. Branch, Brian B. Ghoshhajra, Edward D. Nicol, Andrew D. Choi, and Eric E. Williamson

Subjects
medicine.medical_specialty, Heart disease, Coronavirus disease 2019 (COVID-19), medicine.diagnostic_test, business.industry, valvular heart disease, Computed tomography, medicine.disease, Coronary artery disease, Clinical Practice, Analytics, On demand, Medicine, Radiology, Nuclear Medicine and imaging, Medical physics, Cardiology and Cardiovascular Medicine, business
Abstract

The 16th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting welcomed 781 digital attendees from 55 countries. The program included 27 sessions across three simultaneously streaming channels, 11 exhibitors, 153 poster presentations, and 32 ​hours of on demand videos. The main themes of the meeting included coronary artery disease, valvular heart disease, structural heart disease, and advanced analytics including machine learning. This article summaries the main themes of the meeting and some of the key presentations, which will shape the future of cardiovascular computed tomography in clinical practice.

Published
2021

23. Association of coronary artery calcium score with qualitatively and quantitatively assessed adverse plaque on coronary CT angiography in the SCOT-HEART trial

Author

Damini Dey, Philip D Adamson, Giles Roditi, David E. Newby, Marc R. Dweck, Maia Osborne-Grinter, Jonathan R. Weir-McCall, Sebastien Cadet, Mhairi K. Doris, Shirjel Alam, Edwin J R van Beek, Michelle C. Williams, Jacek Kwiecinski, Nicholas L. Mills, Priscilla McElhinney, Edward D. Nicol, Anoop S V Shah, Piotr J. Slomka, Leslee J. Shaw, Tania Pawade, Amanda Hunter, Daniel S. Berman, Chengjia Wang, and Alastair J Moss

Subjects
medicine.medical_specialty, Computed Tomography Angiography, Myocardial Infarction, Computed tomography, Coronary Artery Disease, Disease, Coronary Angiography, Chest pain, Risk Assessment, low-attenuation plaque, Coronary artery disease, Predictive Value of Tests, Risk Factors, Internal medicine, medicine, Humans, Radiology, Nuclear Medicine and imaging, Myocardial infarction, Vascular Calcification, Atherosclerotic plaque, Original Paper, Framingham Risk Score, medicine.diagnostic_test, business.industry, Coronary artery calcium score, computed tomography, General Medicine, computed tomography coronary angiography, medicine.disease, Coronary calcium score, Plaque, Atherosclerotic, Coronary Calcium Score, Cardiology, Calcium, medicine.symptom, Tomography, X-Ray Computed, Cardiology and Cardiovascular Medicine, business
Abstract

Aims Coronary artery calcification is a marker of cardiovascular risk, but its association with qualitatively and quantitatively assessed plaque subtypes is unknown. Methods and results In this post-hoc analysis, computed tomography (CT) images and 5-year clinical outcomes were assessed in SCOT-HEART trial participants. Agatston coronary artery calcium score (CACS) was measured on non-contrast CT and was stratified as zero (0 Agatston units, AU), minimal (1–9 AU), low (10–99 AU), moderate (100–399 AU), high (400–999 AU), and very high (≥1000 AU). Adverse plaques were investigated by qualitative (visual categorization of positive remodelling, low-attenuation plaque, spotty calcification, and napkin ring sign) and quantitative (calcified, non-calcified, low-attenuation, and total plaque burden; Autoplaque) assessments. Of 1769 patients, 36% had a zero, 9% minimal, 20% low, 17% moderate, 10% high, and 8% very high CACS. Amongst patients with a zero CACS, 14% had non-obstructive disease, 2% had obstructive disease, 2% had visually assessed adverse plaques, and 13% had low-attenuation plaque burden >4%. Non-calcified and low-attenuation plaque burden increased between patients with zero, minimal, and low CACS (P 1000 AU and low-attenuation plaque burden were the only predictors of myocardial infarction, independent of obstructive disease, and 10-year cardiovascular risk score. Conclusion In patients with stable chest pain, zero CACS is associated with a good but not perfect prognosis, and CACS cannot rule out obstructive coronary artery disease, non-obstructive plaque, or adverse plaque phenotypes, including low-attenuation plaque.

Published
2021

24. Altered lung physiology in two cohorts after COVID-19 infection as assessed by computed cardiopulmonography

Author

Snapper R. M. Magor-Elliott, Asma Alamoudi, Rebecca R. Chamley, Haopeng Xu, Tishan Wellalagodage, Rory P. McDonald, David O’Brien, Jonathan Collins, Ben Coombs, James Winchester, Ed Sellon, Cheng Xie, Dominic Sandhu, Christopher J. Fullerton, John H. Couper, Nicholas M. J. Smith, Graham Richmond, Mark P. Cassar, Betty Raman, Nick P. Talbot, Alexander N. Bennett, Edward D. Nicol, Grant A. D. Ritchie, Nayia Petousi, David A. Holdsworth, and Peter A. Robbins

Subjects
Physiology, Physiology (medical), Respiration, Humans, COVID-19, Respiration, Artificial, Lung, Respiratory Function Tests
Abstract

The longer-term effects of COVID-19 on lung physiology remain poorly understood. Here, a new technique, computed cardiopulmonography (CCP), was used to study two COVID-19 cohorts (MCOVID and C-MORE-LP) at both ∼6 and ∼12 mo after infection. CCP is comprised of two components. The first is collection of highly precise, highly time-resolved measurements of gas exchange with a purpose-built molecular flow sensor based around laser absorption spectroscopy. The second component is estimation of physiological parameters by fitting a cardiopulmonary model to the data set. The measurement protocol involved 7 min of breathing air followed by 5 min of breathing pure O2. One hundred seventy-eight participants were studied, with 97 returning for a repeat assessment. One hundred twenty-six arterial blood gas samples were drawn from MCOVID participants. For participants who had required intensive care and/or invasive mechanical ventilation, there was a significant increase in anatomical dead space of ∼30 mL and a significant increase in alveolar-to-arterial Po2 gradient of ∼0.9 kPa relative to control participants. Those who had been hospitalized had reductions in functional residual capacity of ∼15%. Irrespectively of COVID-19 severity, participants who had had COVID-19 demonstrated a modest increase in ventilation inhomogeneity, broadly equivalent to that associated with 15 yr of aging. This study illustrates the capability of CCP to study aspects of lung function not so easily addressed through standard clinical lung function tests. However, without measurements before infection, it is not possible to conclude whether the findings relate to the effects of COVID-19 or whether they constitute risk factors for more serious disease. NEW & NOTEWORTHY This study used a novel technique, computed cardiopulmonography, to study the lungs of patients who have had COVID-19. Depending on severity of infection, there were increases in anatomical dead space, reductions in absolute lung volumes, and increases in ventilation inhomogeneity broadly equivalent to those associated with 15 yr of aging. However, without measurements taken before infection, it is unclear whether the changes result from COVID-19 infection or are risk factors for more severe disease.

Published
2022

26. 3 Cardiopulmonary, functional, cognitive and mental health outcomes post covid, across the range of severity of acute illness, in a physically active working age population: baseline findings from the MCOVID study

Author

Oliver O’Sullivan, David A Holdsworth, Peter Ladlow, Robert M Barker-Davies, Rebecca Chamley, Andrew Houston, Samantha May, Dominic Dewson, Daniel Mills, Kayleigh Pierce, James Mitchell, Cheng Xie, Edward Sellon, Jon Naylor, Joseph Mulae, Mark Cranley, Nick P Talbot, Oliver J Rider, Edward D Nicol, and Alexander N Bennett

Subjects
General Medicine
Abstract

BackgroundThe medium-long impact of coronavirus disease 2019 (COVID-19) on active populations is yet to be fully understood, with potential individual and operational impact on military service personnel (SP). The M-COVID study was established to investigate cardiopulmonary, functional, cognitive, and mental health post-COVID-19 SP outcomes, across the spectrum of acute COVID-19 severity.MethodObservational four-cohort study; hospitalised, community-based illness with on-going symptoms (communitysymptomatic), community-based illness now recovered (community-recovered) and age, sex, job-role matched control. Participants underwent extensive clinical assessment involving cardiopulmonary imaging, submaximal and maximal exercise testing, pulmonary function, cognitive assessment, blood tests, electrocardiogram and questionnaires on mental health and physical function.Results113 participants (aged 39±9, 86% male) were recruited; Hospitalised (n=35), community-symptomatic (n=34), community-recovered (n=18) and control (n=26), 159±72 days following acute illness. Hospitalised and community-symptomatic groups were older (p=0.003), with a higher body mass index (pConclusionsRecovered SP who suffered mild-moderate COVID-19 do not differ from an age, sex and job-role matched controls. This is reassuring for the vast majority of individuals who have had acute COVID-19 not requiring hospital management. Individuals who were hospitalised or continue to suffer symptoms may require a specific, comprehensive clinical and occupational assessment prior to a full return to duty.

Published
2023

27. Reply

Author

Jonathan R. Weir-McCall, Michelle C. Williams, James H.F. Rudd, David E. Newby, and Edward D. Nicol

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Published
2023

28. Initial Invasive or Conservative Strategy for Stable Coronary Disease

Author

Maron D. J., Hochman J. S., Reynolds H. R., Bangalore S., O'Brien S. M., Boden W. E., Chaitman B. R., Senior R., Lopez-Sendon J., Alexander K. P., Lopes R. D., Shaw L. J., Berger J. S., Newman J. D., Sidhu M. S., Goodman S. G., Ruzyllo W., Gosselin G., Maggioni A. P., White H. D., Bhargava B., Min J. K., John Mancini G. B., Berman D. S., Picard M. H., Kwong R. Y., Ali Z. A., Mark D. B., Spertus J. A., Krishnan M. N., Elghamaz A., Moorthy N., Hueb W. A., Demkow M., Mavromatis K., Bockeria O., Peteiro J., Miller T. D., Szwed H., Doerr R., Keltai M., Selvanayagam J. B., Gabriel Steg P., Held C., Kohsaka S., Mavromichalis S., Kirby R., Jeffries N. O., Harrell F. E., Rockhold F. W., Broderick S., Bruce Ferguson T., Williams D. O., Harrington R. A., Stone G. W., Rosenberg Y, ISCHEMIA Research Group: Joseph Ricci, A Tello Montoliu, A I Robero Aniorte, Abbey Mulder, Abhay A Laddu, Abhinav Goyal, Abhishek Dubey, Abhishek Goyal, Abigail Knighton, Abraham Oomman, Adam J Jaskowiak, Adam Kolodziej, Adam Witkowski, Adnan Hameed, Adriana Anesini, Afshan Hussain, Agne Juceviciene, Agne Urboniene, Agnes Jakal, Agnieszka Szramowska, Ahmad Khairuddin, Ahmed Abdel-Latif, Ahmed Adel, Ahmed Aljzeeri, Ahmed Kamal, Ahmed Talaat, Aimee Mann, Aira Contreras, Ajit Kumar, V K Kumar, Akemi Furukawa, Akshay Bagai, Akvile Smigelskaite, Alain Furber, Alain Rheault, Alaine Melanie Loehr, Alan Rosen, Albert Varga, Albertina Qelaj, Alberto Barioli, Aldo Russo, Alec Moorman, Alejandro Gisbert, Aleksandra Fratczak, Aleksandras Laucevicius, Alena Kuleshova, Alessandro Sionis, Alexander A Sirker, Alexander M Chernyavskiy, Alexandra Craft, Alexandra Vazquez, Alexandre Ciappina Hueb, Alexandre S Colafranseschi, Alexandre Schaan de Quadros, Alexandre Tognon, Ali Alghamdi, Alice Manica Muller, Aline Nogueira Rabaça, Aline Peixoto Deiro, Alison Hallam, Allegra Stone, Allison Schley, Almudena Castro, Alvaro Rabelo Ales, Amanda Germann, Amanda O'Malley, Amar Uxa, Amarachi Ojajuni, Amarino C Oliveira Jr, Amber B Hull, Ambuj Roy, Amer Zarka, Amir Janmohamed, Ammani Brown, Ammy Malinay, Amparo Martinez Monzonis, Amy J Richards, Amy Iskandrian, Amy Ollinger, Ana D Djordjevic-Dikic, Ana Fernández Martínez, Ana Gomes Almeida, Ana Paula Batista, Ana Rita Francisco, Ana S Mladenovic, Ana Santana, Anam Siddiqui, Anastasia M Kuzmina-Krutetskaya, Andras Vertes, Andre S Sousa, Andre Gabriel, André Schmidt, Andrea M Lundeen, Andrea Bartykowszki, Andrea Lorimer, Andrea Mortara, Andrea Pascual, Andreia Coelho, Andreia Rocha, Andrés García-Rincón, Andrew G Howarth, Andrew J Moriarty, Andrew Docherty, Andrew Starovoytov, Andrew Zurick, Andrzej Łabyk, Andrzej Swiatkowski, Andy Lam, Anelise Kawakami, Angela Hoye, Angela Kim, Angelique Smit, Angelo Nobre, Anil V Shah, Anja Ljubez, Anjali Anand, Ankush Sachdeva, Ann Greenberg, Ann Luyten, Ann Ostrander, Anna Di Donato, Anna Cichocka-Radwan, Anna Fojt, Anna Plachcinska, Anna Proietti, Anna Teresinska, Anne Marie Webb, Anne Cartwright, Anne Heath, Anne Mackin, Anong Amaritakomol, Anong Chaiyasri, Anoop Chauhan, Anoop Mathew, Anthony Gemignani, Anto Luigi Andres, Antonia Vega, Antonietta Hansen, Antonino Ginel Iglesias, Antonio Carlos Carvalho, Antonio Di Chiara, Antonio Serra Peñaranda, Antonio Carvalho, Antonio Colombo, Antonio Fiarresga, Anupama Rao, Aquiles Valdespino-Estrada, Araceli Boan, Areef Ishani, Ariel Diaz, Arijit Ghosh, Arintaya Prommintikul, Arline Roberts, Arnold H Seto, Arnold P Good, Arshed Quyyumi, Arthur J Labovitz, Arthur Kerner, Arturo S Campos-Santaolalla, Arunima Misra, Ashok Mukherjee, Ashok Seth, Ashraf Seedhom, Asim N Cheema, Asker Ahmed, Atul Mathur, Atul Verma, Audrey W Leong, Axel Åkerblom, Axelle Fuentes, Aynun Naher, Badhma Valaiyapathi, Baljeet Kaur, Bandula Guruge, Barbara Brzezińska, Barbara Nardi, Bartosz Czarniak, Bebek Singh, Begoña Igual, Bela Merkely, Belen Cid Alvarez, Benjamin J Spooner, Benjamin J W Chow, Benjamin Cheong, Benoy N Shah, Bernard de Bruyne, Bernardas Valecka, Bernhard Jäger, Beth A Archer, Beth Abramson, Beth Jorgenson, Bethany Harvey, Betsy O'Neal, Bev Atkinson, Bev Bozek, Bevin Lang, Bijulal Sasidharan, Bin Yang, Bin Zhang, Binoy Mannekkattukudy Kurian, Bjoern Goebel, Bob Hu, Bogdan A Popescu, Bogdan Crnokrak, Bolin Zhu, Bonnie J Kirby, Brandi D Zimbelman, Brandy Starks, Branko D Beleslin, Brenda Hart, Brian P Shapiro, Brian McCandless, Brianna Wisniewski, Brigham R Smith, Brooks Mirrer, Bruce McManus, Bruce Rutkin, Bruna Edilena Paulino, Bruna Maria Ascoli, Bryn Smith, Byron J Allen, C Michael Gibson, C Noel Bairey Merz, Calin Pop, Cameron Hague, Camila Thais de Ormundo, Candace Gopaul, Candice P Edillo, Carísi A Polanczyk, Carita Krannila, Carla Vicente, Carl-Éric Gagné, Carlo Briguori, Carlos Peña Gil, Carlos Alvarez, Carly Ohmart, Carmen C Beladan, Carmen Ginghina, Carol M Kartje, Caroline Alsweiler, Caroline Brown, Caroline Callison, Caroline Pinheiro, Caroline Rodgers, Caroline Spindler, Carolyn Corbett, Carrie Drum, Casey Riedberger, Catherine Bone, Catherine Fleming, Catherine Gordon, Catherine Jahrsdorfer, Catherine Lemay, Catherine Weick, Cathrine Patten, Cecilia Goletto, Cezary Kepka, Chandini Suvarna, Chang Xu, Chantale Mercure, Charle A Viljoen, Charlene Wiyarand, Charles Jia-Yin Hou, Charles Y Lui, Charles Cannan, Charles Cornet, Charlotte Pirro, Chataroon Rimsukcharoenchai, Chen Wang, Cheng-Ting Tsai, Chen-Yen Chien, Cheryl A Allardyce, Chester M Hedgepeth, Chetan Patel, Chiara Attanasio, Chih-Hsuan Yen, Chi-Ming Chow, Ching Min Er, Ching-Ching Ong, Cholenahally Nanjappa Manjunath, Chris Beck, Chris Buller, Christel Vassaliere, Christian Hamm, Christiano Caldeira, Christie Ballantyne, Christina Björklund, Christine R Hinton, Christine Bergeron, Christine Masson, Christine Roraff, Christine Shelley, Christophe Laure, Christophe Thuaire, Christopher Kinsey, Christopher McFarren, Christopher Spizzieri, Christopher Travill, Chun-Chieh Liu, Chung-Lieh Hung, Chunguang Li, Chun-Ho Yun, Chunli Xia, Ciarra Heard, Cidney Schultz, Clare Venn-Edmonds, Claudia P Hochberg, Claudia Wegmayr, Claudia Cortés, Claudia Escobar, Cláudia Freixo, Claudio T Mesquita, Clemens T Kadalie, Colin Berry, Constance Philander, Corine Thobois, Costantino Costantini, Courtney Page, Craig Atkinson, Craig Barr, Craig Paterson, Cristina Bare, Cynthia Baumann, Cynthia Burman, Dalisa Espinosa, Damien Collison, Dan Deleanu, Dan Elian, Dan Gao, Dana Oliver, Daniel P Vezina, Daniel O'Rourke, Daniele Komar, Danielle Schade, Darrel P Francis, Dastan Malaev, David A Bull, David E Winchester, David P Faxon, David Booth, David Cohen, David DeMets, David Foo, David Schlichting, David Taggart, David Waters, David Wohns, Davis Vo, Dawid Teodorczyk, Dawn Shelstad, Dawn Turnbull, Dayuan Li, Dean Kereiakes, Deborah O'Neill, Deborah Yip, Debra K Johnson, Debra Dees, Deepak L Bhatt, Deepika Gopal, Deepti Kumar, Deirdre Mattina, Deirdre Murphy, Delano R Small, Delsa K Rose, Dengke Jiang, Denis Carl Phaneuf, Denise Braganza, Denise Fine, Derek Cyr, Desiree Tobin, Diana Cukali, Diana Parra, Diane Camara, Diane Minshall Liu, Diego Adrián Vences, Diego Franca de Cunha, Dimitrios Stournaras, Dipti Patel, Dongze Li, Donna Exley, Dorit Grahl, Dragana Stanojevic, Duarte Cacela, Dwayne S G Conway, E Pinar Bermudez, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Edoardo Verna, Eduardo Hernandez-Rangel, Edward D Nicol, Edward O McFalls, Edward T Martin, Edyta Kaczmarska, Ekaterina I Lubinskaya, Elena A Demchenko, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise L Hannemann, Elise van Dongen, Elissa Restelli Piloto, Eliza Kaplan, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizabeth Congdon, Elizabeth Ferguson, Elizaveta V Zbyshevskaya, Ellen Magedanz, Ellie Fridell, Ellis W Lader, Elvin Kedhi, Emanuela Racca, Emilie Tachot, Emily DeRosa, Encarnación Alonso-Álvarez, Eric Nicollet, Eric Peterson, Erick Alexánderson Rosas, Erick Donato Morales, Erin Orvis, Ermina Moga, Estelle Montpetit, Estevao Figueiredo, Eugene Passamani, Eugenia Nikolsky, Eunice Yeoh, Evgeniy I Kretov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, F Marin Ortuño, Fabio R Farias, Fabio Fimiani, Fabrizio Rolfo, Fa-Chang Yu, Fadi Hage, Fadi Matar, Fahim Haider Jafary, Fang Feng, Fang Liu, Fatima Ranjbaran, Fatima Rodriguez, Fausto J Pinto, Fauzia Rashid, Federica Ramani, Fei Wang, Fernanda Igansi, Filipa Silva, Filippo Ottani, Fiona Haines, Firas Al Solaiman, Flávia Egydio, Flavio Lyra, Florian Egger, Fran Farquharson, Frances Laube, Francesc Carreras Costa, Francesca de Micco, Francesca Bianchini, Francesca Pezzetta, Francesca Pietrucci, Francesco Orso, Francesco Pisano, Francis Burt, Francisca Patuleia Figueiras, Francisco Fernandez-Aviles, Francois Pierre Mongeon, Frans Van de Werf, Franziska Guenther, Fraser N Witherow, Fred Mohr, Frederico Dall'Orto, Fumiyuki Otsuka, G De La Morena, G Karthikeyan, Gabor Dekany, Gabor Kerecsen, Gabriel Galeote, Gabriel Grossmann, Gabriel Vorobiof, Gabriela Sanchez de Souza, Gabriela Guzman, Gabriela Zeballos, Gabriele Gabrielli, Gabriele Jakl-Kotauschek, Gail A Shammas, Gail Brandt, Gang Chen, Gary E Lane, Gary J Luckasen, Gautam Sharma, Gelmina Mikolaitiene, Gennie Yee, Georg Nickenig, George E Revtyak, George J Juang, Gerald Fletcher, Gerald Leonard, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Geza Fontos, Ghada Mikhail, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Giles Roditi, Gilles Barone-Rochette, Girish Mishra, Giuseppe Tarantini, Glenda Wong, Glenn S Hamroff, Glenn Rayos, Gong Cheng, Gonzalo Barge-Caballero, Goran Davidović, Goran Stankovic, Gordana Stevanovic, Grace Jingyan Wang, Grace M Young, Graceanne Wayser, Graciela Scaro, Graham S Hillis, Graham Wong, Grazyna Anna Szulczyk, Gregor Simonis, Gregory Kumkumian, Gretchen Ann Peichel, Grzegorz Gajos, Gudrun Steinmaurer, Guilherme G Rucatti, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillem Pons Lladó, Gunnar Frostfelt, Gurpreet S Wander, Gurpreet Gulati, Gustavo Pucci, Hafidz Abd Hadi, Haibo Zhang, Haitao Wang, Halina Marciniak, Han Chen, Hanan Kerr, Hani Najm, Hanna Douglas, Hannah Phillips, Hao Dai, Haojian Dong, Haqeel Jamil, Harikrishnan Sivadasanpillai, Harry Suryapranata, Hassan Reda, Hayley Pomeroy, Heather Barrentine, Heather Golden, Heather Hurlburt, Heidi Wilson, Helen C Tucker, Helene Abergel, Hemalata Siddaram, Hermine Osseni, Herwig Schuchlenz, Hesong Zeng, Hicham Skali, Hilda Solomon, Hollie Horton, Holly Hetrick, Holly Little, Holly Park, Hongjie Chi, Hossam Mahrous, Howard A Levite, Hristo Pejkov, Huajun Li, Hugo Bloise-Adames, Hugo Marques, Hui Zhong, Hui-Min Zhang, Humayrah Hashim, Hung-I Yeh, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ihab Hamzeh, Ikraam Hassan, Ikuko Ueda, Ileana L Pina, Ilona Tamasauskiene, Ilse Bouwhuis, Imran Arif, Ina Wenzelburger, Inês Zimbarra Cabrita, Ines Rodrigues, Inga H Robbins, Inga Soveri, Ingela Schnittger, Iqbal Karimullah, Ira M Dauber, Iram Rehman, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Irni Yusnida, Isabel Estela Carvajal, Isabella C Palazzo, Isabelle Hogan, Isabelle Roy, Ishba Syed, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, J David Knight, Jacek Kusmierek, Jackie M White, Jackie Chow, Jacob Udell, Jacqueline E Tamis-Holland, Jacqueline Fannon, Jacquelyn A Quin, Jacquelyn Do, Jaekyeong Heo, Jakub Maksym, James E Davies, James H O'Keefe Jr, James J Jang, James Cha, James Harrison, James Hirsch, James Stafford, James Tatoulis, Jamie Rankin, Jan Henzel, Jan Orga, Jana Tancredi, Janaina Oliveira, Jane Burton, Jane Eckstein, Jane Marucci, Janet P Knight, Janet Blount, Janet Halliday, Janetta Kourzenkova, Janitha Raj, Jan-Malte Sinning, Jaqueline Pozzibon, Jaroslaw Drozdz, Jaroslaw Karwowski, Jason D Glover, Jason Loh Kwok, Jason T Call, Jason Linefsky, Jassira Gomes, Jati Anumpa, Javier J Garcia, Javier Courtis, Jay Meisner, K Jayakumar, Jayne Scales, Jean E Denaro, Jean Michel Juliard, Jean Ho, Jeanette K Stansborough, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeet Thambyrajah, Jeff Leimberger, Jeffery A Breall, Jeffrey A Kohn, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Blume, Jeffrey Kanters, Jeffrey Lorin, Jeffrey Moses, Jelena J Stepanovic, Jelena Celutkiene, Jelena Djokic, Jelena Stojkovic, Jenne M Jose, Jenne Manchery, Jennifer A Mull, Jennifer H Czerniak, Jennifer L Stanford, Jennifer Gillis, Jennifer Horst, Jennifer Isaacs, Jennifer Langdon, Jennifer Thomson, Jennifer Tomfohr, Jennifer White, Jen-Yuan Kuo, Jeremy Rautureau, Jerome Fleg, Jessica Berg, Jessica Rodriguez, Jessica Waldron, Jhina Patro, Jia Li, Jiajia Mao, Jiamin Liu, Jian'an Wang, Jianhua Li, Jianxin Zhang, Jie Qi, Jihyun Lyo, Jill Marcus, Jim Blankenship, Jing Zhang, Jingjing Liu, Jing-Yao Fan, Jiun-Yi Li, Jiwan Pradhan, Jiyan Chen, J M Rivera Caravaca, Jo Evans, Joan Garcia Picart, Joan Hecht, Joanna Jaroch, Joanna Zalewska, Joanne Kelly, Joanne Taaffe, João Reynaldo Abbud, João V Vitola, Joaquín V Peñafiel, Jocelyne Benatar, Jody Bindeman, Joe Sabik, Joel Klitch, Johann Christopher, Johannes Aspberg, John D Friedman, John F Beltrame, John F Heitner, John Joseph Graham, John R Davies, John Doan, John Kotter, John Kurian, John Mukai, John Pownall, Jolanta Sobolewska, Jon Kobashigawa, Jonathan L Goldberg, Jonathan W Bazeley, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Leipsic, Jonean Thorsen, Jorge F Trejo Gutierrez, Jorge Escobedo, Jorik Timmer, José A Ortega-Ramírez, José Antonio Marin-Neto, Jose D Salas, Jose Enrique Castillo, Jose Francisco Saraiva, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Vieira, José M Flores-Palacios, Jose Ramon Gonzalez, Jose Seijas Amigo, Jose Fragata, Josep Maria Padró, Josheph F X McGarvey Jr, Joseph Hannan, Joseph Sacco, Joseph Sweeny, Joseph Wiesel, Josephine D Abraham, Joshua P Loh, Joy Burkhardt, Joyce R White, Joyce Riestenberg-Smith, Judit Sebo, Judith L Meadows, Judith Wright, Judy Mae Foltz, Judy Hung, Judy Otis, Juergen Stumpf, Jui-Peng Tsai, Julia S Dionne, Julia de Aveiro Morata, Julie Bunke, Julie Morrow, Julio César Figal, Jun Fujita, Jun Jiang, Junhua Li, Junqing Yang, Juntima Euathrongchit, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Kai Eggers, Kamalakar Surineni, Kanae Hirase, T R Kapilamoorthy, Karen Calfas, Karen Gratrix, Karen Hallett, Karen Hultberg, Karen Nugent, Karen Petrosyan, Karen Swan, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karsten Lenk, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Kate Pointon, Kate Robb, Katherine Martin, Kathleen Claes, Kathryn Carruthers, Kathy E Siegel, Katia Drouin, Katie Fowler-Lehman, Kavita Rawat, Kay Rowe, Keiichi Fukuda, Keith A A Fox, Ken Mahaffey, Kendra Unterbrink, Kenneth Giedd, Kerrie Van Loo, Kerry Lee, Kerstin Bonin, Kevin R Bainey, Kevin T Harley, Kevin Anstrom, Kevin Chan, Kevin Croce, Kevin Landolfo, Kevin Marzo, Keyur Patel, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khaled Ziada, Khaula Baloch, Khrystyna Kushniriuk, Kian-Keong Poh, Kim F Ireland, Kim Holland, Kimberly Ann Byrne, Kimberly E Halverson, Kimberly Elmore, Kimberly Miller-Cox, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kotiboinna Preethi, Kozhaya Sokhon, Krissada Meemuk, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristina Wippler, Kristine Arges, Kristine Teoh, Krystal Etherington, Krystyna Łoboz-Grudzień, Krzysztof W Reczuch, Krzysztof Bury, Krzysztof Drzymalski, Krzysztof Kukuła, Kuo-Tzu Sung, Kurt Huber, Ladda Douangvila, Lance Sullenberger, Larissa Miranda Trama, Laszlone Matics, Laura Drew, Laura Flint, Laura Keinaite, Laura Sarti, Laurel Kolakaluri, Lawrence M Phillips, Lawrence Friedman, Lawrence Phillips, Lazar Velicki, Leah Howell, Leandro C Maranan, Leanne Cox, Ledjalem Daba, Lei Zhang, Lekshmi Dharmarajan, Leo Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Leszek Sokalski, Li Hai Yan, Li Li, Lia Nijmeijer, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilia Schiavi, Lilian Mazza Barbosa, Lillian L Khor, Lina Felix-Stern, Linda L Hall, Linda M Hollenweger, Linda Arcand, Linda Davidson-Ray, Linda Schwarz, Lindsey N Sikora, Lingping Chi, Lino Patricio, Liping Zhang, Lisa Chaytor, Lisa Hatch, Lisa McCloy, Lisa Wong, Liselotte Persson, Lixin Jiang, Liz Low, Ljiljana Pupic, Loïc Bière, Lorenzo Monti, Lori Christensen, Lori Pritchard, Loriane Black, Lori-Ann Desimone, Lori-Ann Larmand, Lorraine McGregor, Louise Morby, Louise Thomson, Luc Harvey, Luciana de Pádua Baptista, Lucilla Garcia, Ludivine Eliahou, Ludmila Helmer, Luis F Smidt, Luis Bernanrdes, Luis Guzman, Luiz A Carvalho, Luyang Xiong, Lynette L Teo, Lynn M Neeson, Lynne Winstanley, M Barbara Srichai-Parsia, M Quintana Giner, M Sowjanya Reddy, M Valdés Chávarri, M Grazia Rossi, Maarten Simoons, Maayan Konigstein, Maciej Lesiak, Maciej Olsowka, Mafalda Selas, Magalie Corfias, Magdalena Madero Rovalo, Magdalena Łanocha, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdalena Rantinella, Magdy Abdelhamid, Magnolia Jimenez, Mahboob Alam, Mahevamma Mylarappa, Mahfouz El Shahawy, Mahmoud Mohamed, Mahmud Al-Bustami, Majo X Joseph, Malgorzata Frach, Małgorzta Celińska-Spodar, Malte Helm, Manas Chacko, Mandy Murphy, Manitha Vinod, Manjula Rani, Manu Dhawan, Manuela Mombelli, Marcel Weber, Marcello Galvani, Marcelo Jamus Rodrigues, Marcia F Dubin, Marcia F Werner Bayer, Marcin Szkopiak, Marco Antonio Monsalve, Marco Bizzaro Santos, Marco Magnoni, Marco Marini, Marco Sicuro, Marco Zenati, Marcos Valério Coimbra Resende, Marek Roik, Margalit Bentzvi, Margaret Gilsenan, Margaret Iraola, Margot C 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George J Juang, Gerald Fletcher, Gerald Leonard, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Geza Fontos, Ghada Mikhail, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Giles Roditi, Gilles Barone-Rochette, Girish Mishra, Giuseppe Tarantini, Glenda Wong, Glenn S Hamroff, Glenn Rayos, Gong Cheng, Gonzalo Barge-Caballero, Goran Davidović, Goran Stankovic, Gordana Stevanovic, Grace Jingyan Wang, Grace M Young, Graceanne Wayser, Graciela Scaro, Graham S Hillis, Graham Wong, Grazyna Anna Szulczyk, Gregor Simonis, Gregory Kumkumian, Gretchen Ann Peichel, Grzegorz Gajos, Gudrun Steinmaurer, Guilherme G Rucatti, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillem Pons Lladó, Gunnar Frostfelt, Gurpreet S Wander, Gurpreet Gulati, Gustavo Pucci, Hafidz Abd Hadi, Haibo Zhang, Haitao Wang, Halina Marciniak, Han Chen, Hanan Kerr, Hani Najm, Hanna Douglas, Hannah Phillips, Hao Dai, Haojian Dong, Haqeel Jamil, Harikrishnan Sivadasanpillai, Harry Suryapranata, Hassan Reda, Hayley Pomeroy, Heather Barrentine, Heather Golden, Heather Hurlburt, Heidi Wilson, Helen C Tucker, Helene Abergel, Hemalata Siddaram, Hermine Osseni, Herwig Schuchlenz, Hesong Zeng, Hicham Skali, Hilda Solomon, Hollie Horton, Holly Hetrick, Holly Little, Holly Park, Hongjie Chi, Hossam Mahrous, Howard A Levite, Hristo Pejkov, Huajun Li, Hugo Bloise-Adames, Hugo Marques, Hui Zhong, Hui-Min Zhang, Humayrah Hashim, Hung-I Yeh, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ihab Hamzeh, Ikraam Hassan, Ikuko Ueda, Ileana L Pina, Ilona Tamasauskiene, Ilse Bouwhuis, Imran Arif, Ina Wenzelburger, Inês Zimbarra Cabrita, Ines Rodrigues, Inga H Robbins, Inga Soveri, Ingela Schnittger, Iqbal Karimullah, Ira M Dauber, Iram Rehman, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Irni Yusnida, Isabel Estela Carvajal, Isabella C Palazzo, Isabelle Hogan, Isabelle Roy, Ishba Syed, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, J David Knight, Jacek Kusmierek, Jackie M White, Jackie Chow, Jacob Udell, Jacqueline E Tamis-Holland, Jacqueline Fannon, Jacquelyn A Quin, Jacquelyn Do, Jaekyeong Heo, Jakub Maksym, James E Davies, James H O'Keefe Jr, James J Jang, James Cha, James Harrison, James Hirsch, James Stafford, James Tatoulis, Jamie Rankin, Jan Henzel, Jan Orga, Jana Tancredi, Janaina Oliveira, Jane Burton, Jane Eckstein, Jane Marucci, Janet P Knight, Janet Blount, Janet Halliday, Janetta Kourzenkova, Janitha Raj, Jan-Malte Sinning, Jaqueline Pozzibon, Jaroslaw Drozdz, Jaroslaw Karwowski, Jason D Glover, Jason Loh Kwok, Jason T Call, Jason Linefsky, Jassira Gomes, Jati Anumpa, Javier J Garcia, Javier Courtis, Jay Meisner, K Jayakumar, Jayne Scales, Jean E Denaro, Jean Michel Juliard, Jean Ho, Jeanette K Stansborough, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeet Thambyrajah, Jeff Leimberger, Jeffery A Breall, Jeffrey A Kohn, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Blume, 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Vincent Setang, C P Vineeth, Virginai Pubull Nuñez, Virginia Fernández-Figares, Vitor Gomes, Viviana Gabriel, Viviane Dos Santos, Viviane Almeida, Vlad A Iliescu, Vladan Mudrenovic, Vladimir Dzavik, Vojislav L Giga, Walter Enrique Mogrovejo, Wan Xian Chan, Wanda C Marfori, Wanda Parker, Warangkana Mekara, Wassim Nona, Wayne Old, Wayne Pennachi, Weerachai Nawarawong, Wei Chen, Wei Su, Weibing Xing, Wei-Ren Lan, Wenda Crawford, Wendy L Stewart, Wendy Drewes, Wenhua Lin, William B Abernethy, William D Salerno, William F Fearon, William Vergoni, William Weintraub, Winnie C Sia, Wlodzimierz J Musial, Xacobe Flores-Ríos, Xavier Garcia-Moll Marimon, Xi Su, Xiang Ma, Xiangqiong Gu, Xiao Wang, Xiaomei Li, Xiaowei Yao, Xin Fu, Xin Su, Xin Zeng, Xinchun Yang, Xiuhong Li, Xuehua Fang, Xutong Wang, Yaming Geng, Yan Yan, Yanek Pépin-Dubois, Yanfu Wang, Yang Wang, Yanmeng Tian, Yaping Huang, Yechen Han, Yesenia Zambrano, Yi-Hsuan Yang, Ying Tung Sia, Yining Yang, Yitong Ma, Yolayfi Peralta, Yongjian Wu, Yu Kunwu, Yu Zhao, Yudong Peng, Yueh-Hung Lin, Yulan Zhao, Yumei Dong, Yunhai Zhao, Yutthaphan Wannasopha, Yvonne Taul, Zakir Sahul, Zalina Kudzoeva, Zbigniew Kalarus, Zeljko Z Markovic, Zhen Huang, Zheng Ji, Zhenyu Liu, Zhou Yue, Zhulin Zhang, Zhuxi Li, Zile Singh Meharwal, Ziliang Bai, Zixiang Yu, Zohra Huda, Zoltan Davidovits

Subjects
Male, Cardiac Catheterization, Computed Tomography Angiography, medicine.medical_treatment, Myocardial Ischemia, Coronary Disease, Coronary Artery Disease, Kaplan-Meier Estimate, 030204 cardiovascular system & hematology, Coronary Angiography, ISCHEMIA Research Group, law.invention, Angina, Coronary artery disease, 0302 clinical medicine, Randomized controlled trial, law, Cardiovascular Disease, Myocardial Revascularization, 030212 general & internal medicine, Coronary Artery Bypass, 11 Medical and Health Sciences, Cardiac catheterization, General Medicine, Middle Aged, humanities, Cardiovascular Diseases, Cardiology, Female, Human, medicine.medical_specialty, Ischemia, Article, 03 medical and health sciences, Geriatric cardiology, Percutaneous Coronary Intervention, General & Internal Medicine, Internal medicine, medicine, Humans, Angina, Unstable, Aged, business.industry, Coronary Artery Bypa, Percutaneous coronary intervention, Bayes Theorem, medicine.disease, Heart failure, Quality of Life, business
Abstract

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

Published
2020

29. The role of cardiovascular CT in occupational health assessment for coronary heart disease: An expert consensus document from the Society of Cardiovascular Computed Tomography (SCCT)

Author

Iain T Parsons, Dustin M. Thomas, Billy Chen, Matthew J. Budoff, Ron Blankstein, Prashant Nagpal, Emilio Fentanes, Michael K. Cheezum, Leslee J. Shaw, Kelley R. Branch, Christopher D. Maroules, Todd C. Villines, Ahmad M. Slim, Nishant R. Shah, Edward D. Nicol, and Suhny Abbara

Subjects
Coronary angiography, medicine.medical_specialty, medicine.diagnostic_test, business.industry, Expert consensus, Computed tomography, medicine.disease, Coronary heart disease, Occupational safety and health, Coronary artery disease, Internal medicine, medicine, Cardiology, Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine, business
Published
2021

30. Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement

Author

Edward D. Nicol, Xu Yu Jin, Jiang Ting Hu, Mario Petrou, and John Pepper

Subjects
Aortic valve, medicine.medical_specialty, Catheters, Regurgitation (circulation), Asymptomatic, Muscle hypertrophy, Transcatheter Aortic Valve Replacement, Aortic valve replacement, Internal medicine, medicine, Humans, Aged, Ventricular Remodeling, business.industry, Atrial fibrillation, Aortic Valve Stenosis, General Medicine, medicine.disease, Stenosis, Catheter, Treatment Outcome, medicine.anatomical_structure, Aortic Valve, cardiovascular system, Cardiology, medicine.symptom, business
Abstract

Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.

Published
2021

31. The Journal of cardiovascular computed tomography: A year in review 2021

Author

Márton Kolossváry, Anna B. Reid, Andrea Baggiano, Prashant Nagpal, Arzu Canan, Subhi J. Al’Aref, Daniele Andreini, João L. Cavalcante, Carlo N. de Cecco, Anjali Chelliah, Marcus Y. Chen, Andrew D. Choi, Damini Dey, Timothy Fairbairn, Maros Ferencik, Heidi Gransar, Harvey Hecht, Jonathan Leipsic, Michael T. Lu, Mohamed Marwan, Pál Maurovich-Horvat, Ming-Yen Ng, Edward D. Nicol, Gianluca Pontone, Rozemarijn Vliegenthart, Seamus P. Whelton, Michelle C. Williams, Armin Arbab-Zadeh, Kanwal M. Farooqi, Jonathan Weir-McCall, Gudrun Feuchtner, Todd C. Villines, Cardiovascular Centre (CVC), and ​Basic and Translational Research and Imaging Methodology Development in Groningen (BRIDGE)

Subjects
Cardiac computed tomography, Journal of Cardiovascular Computed Tomography, Settore MED/11 - Malattie dell'Apparato Cardiovascolare, Cardiac computed tomography angiography, Coronary atherosclerosis, Structural heart disease, Prognosis, Cardiovascular Diseases, Predictive Value of Tests, Humans, Radiology, Nuclear Medicine and imaging, Journal Impact Factor, Tomography, X-Ray Computed, Cardiology and Cardiovascular Medicine
Abstract

This review aims to summarize original articles published in the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2021, focusing on those that had the most scientific and educational impact. The JCCT continues to expand; the number of submissions, published manuscripts, cited articles, article downloads, social media presence, and impact factor continues to increase. The articles selected by the Editorial Board of the JCCT in this review focus on coronary artery disease, coronary physiology, structural heart disease, and technical advances in cardiovascular CT. In addition, we highlight key consensus documents and guidelines published in the Journal in 2021. The Journal recognizes the tremendous work done by each author and reviewer this year - thank you.

Published
2022

32. The Journal of Cardiovascular Computed Tomography: 2020 Year in review

Author

Jonathon Leipsic, Michael T. Lu, James P. Earls, Seamus P. Whelton, Maros Ferencik, Damini Dey, Heidi Gransar, Todd C. Villines, Jonathan R. Weir-McCall, Marcus Y. Chen, Carlo N. De Cecco, Gudrun Feuchtner, Andrew D. Choi, Pál Maurovich-Horvat, Armin Arbab-Zadeh, Daniele Andreini, Harvey S. Hecht, Mohamed Marwan, Edward D. Nicol, Gianluca Pontone, Subhi J. Al'Aref, Michelle C. Williams, Weir-McCall, Jonathan [0000-0001-5842-842X], and Apollo - University of Cambridge Repository

Subjects
medicine.medical_specialty, Cardiac computed tomography, Biomedical Research, Heart Diseases, Heart disease, Coronavirus disease 2019 (COVID-19), Computed Tomography Angiography, Computed tomography, Coronary Artery Disease, 030204 cardiovascular system & hematology, Coronary Angiography, Coronary artery calcium, 030218 nuclear medicine & medical imaging, Coronary artery disease, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Pandemic, Cardiac CT, Humans, Medicine, Radiology, Nuclear Medicine and imaging, Social media, Coronary CT angiography, Structural heart disease, Journal of cardiovascular computed tomography, Computed tomography angiography, medicine.diagnostic_test, SARS-CoV-2, business.industry, Year in review, COVID-19, Prognosis, medicine.disease, Family medicine, Host-Pathogen Interactions, Periodicals as Topic, Cardiology and Cardiovascular Medicine, business
Abstract

The purpose of this review is to highlight the most impactful, educational, and frequently downloaded articles published in the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2020. The JCCT reached new records in 2020 for the number of research submissions, published manuscripts, article downloads and social media impressions. The articles in this review were selected by the Editorial Board of the JCCT and are comprised predominately of original research publications in the following categories: Coronavirus disease 2019 (COVID-19), coronary artery disease, coronary physiology, structural heart disease, and technical advances. The Editorial Board would like to thank each of the authors, peer-reviewers and the readers of JCCT for making 2020 one of the most successful years in its history, despite the challenging circumstances of the global COVID-19 pandemic.

Published
2021

33. Oncological outcomes and stoma-free survival following TaTME, a prospective cohort study

Author

S Hallam, Nikolaos Gouvas, Siddharth Pandey, D Nicol, and F Ahmed

Subjects
medicine.medical_specialty, medicine.diagnostic_test, business.industry, Colorectal cancer, General surgery, Gastroenterology, Context (language use), Physical examination, Perioperative, medicine.disease, Colorectal surgery, 03 medical and health sciences, 0302 clinical medicine, 030220 oncology & carcinogenesis, Medicine, 030211 gastroenterology & hepatology, Surgery, Prospective cohort study, business, Survival rate, Abdominal surgery
Abstract

Transanal TME (TaTME) was introduced to improve access to the pelvis in difficult cases (male sex, obesity and mid to low rectal cancers) and reduce the risk of anastomotic leak by avoiding cross stapling. In April 2018 the Norwegian hospital to whom all local; recurrences for rectal cancer are referred reported an unexpected rise in early multifocal local recurrences of 9.5% following TaTME compared with 3.4% following conventional TME leading to a nationwide moratorium on the procedure and ending, in an editorial published on the British Journal of Surgery in August 2020, by saying that other countries should consider the issue in the context of local practices and results. There are limited data concerning oncological outcomes of TaTME compared to conventional TME. The aim of this study was to report perioperative and oncological outcomes for patients with rectal cancer treated with TaTME in a high-volume, experienced UK centre. From January 2015 to January 2020 consecutive patients with histologically confirmed rectal cancer having TaTME at Worcestershire Royal Hospital NHS were prospectively entered into an online international registry. Patients were followed according to local protocol with clinical examination, tumour markers, endoscopy and radiology. Seventy patients underwent TaTME for rectal cancer. The median distance of the tumour from the anorectal junction was 4 cm (IQR 2–5). The mesorectal margin was involved in 20 (1%) patients, all of whom received neoadjuvant chemoradiotherapy. Overall survival was 94% at a median follow-up of 15 months (IQR 9–31 months). Distant recurrence occurred in 12 (17%) of patients at a median of 14 months (IQR 10–17 months). The 18-month stoma-free survival rate was 66%. A local recurrence rate of 5.7% supports the oncological safety of TaTME for rectal cancer.

Published
2021

35. Prevalence of Thrombotic Complications in ICU-Treated Patients With Coronavirus Disease 2019 Detected With Systematic CT Scanning

Author

Suveer Singh, Thomas Semple, Deepa R. J. Arachchillage, Anand Devaraj, Sujal R. Desai, Diana A. Gorog, Carole A. Ridge, Bhavin Rawal, Ciara Mahon, Saeed Mirsadraee, Susanna Price, Simon P. G. Padley, and Edward D. Nicol

Subjects
Thorax, medicine.medical_specialty, medicine.diagnostic_test, business.industry, medicine.medical_treatment, 030208 emergency & critical care medicine, Critical Care and Intensive Care Medicine, medicine.disease, medicine.disease_cause, 03 medical and health sciences, 0302 clinical medicine, medicine.anatomical_structure, 030228 respiratory system, Internal medicine, Coagulopathy, medicine, Extracorporeal membrane oxygenation, Abdomen, Thrombus, business, Pneumonitis, Coronavirus, Partial thromboplastin time
Abstract

OBJECTIVES: Severe coronavirus disease 2019 is associated with an extensive pneumonitis and frequent coagulopathy. We sought the true prevalence of thrombotic complications in critically ill patients with severe coronavirus disease 2019 on the ICU, with or without extracorporeal membrane oxygenation. DESIGN: We undertook a single-center, retrospective analysis of 72 critically ill patients with coronavirus disease 2019-associated acute respiratory distress syndrome admitted to ICU. CT angiography of the thorax, abdomen, and pelvis were performed at admission as per routine institution protocols, with further imaging as clinically indicated. The prevalence of thrombotic complications and the relationship with coagulation parameters, other biomarkers, and survival were evaluated. SETTING: Coronavirus disease 2019 ICUs at a specialist cardiorespiratory center. PATIENTS: Seventy-two consecutive patients with coronavirus disease 2019 admitted to ICU during the study period (March 19, 2020, to June 23, 2020). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All but one patient received thromboprophylaxis or therapeutic anticoagulation. Among 72 patients (male:female = 74%; mean age: 52 ± 10; 35 on extracorporeal membrane oxygenation), there were 54 thrombotic complications in 42 patients (58%), comprising 34 pulmonary arterial (47%), 15 peripheral venous (21%), and five (7%) systemic arterial thromboses/end-organ embolic complications. In those with pulmonary arterial thromboses, 93% were identified incidentally on first screening CT with only 7% suspected clinically. Biomarkers of coagulation (e.g., D-dimer, fibrinogen level, and activated partial thromboplastin time) or inflammation (WBC count, C-reactive protein) did not discriminate between patients with or without thrombotic complications. Fifty-one patients (76%) survived to discharge; 17 (24%) patients died. Mortality was significantly greater in patients with detectable thrombus (33% vs 10%; p = 0.022). CONCLUSIONS: There is a high prevalence of thrombotic complications, mainly pulmonary, among coronavirus disease 2019 patients admitted to ICU, despite anticoagulation. Detection of thrombus was usually incidental, not predicted by coagulation or inflammatory biomarkers, and associated with increased risk of death. Systematic CT imaging at admission should be considered in all coronavirus disease 2019 patients requiring ICU.

Published
2021

36. Hepatosteatosis and Atherosclerotic Plaque at Coronary CT Angiography

Author

Jessica Carter, Thomas D. Heseltine, Mohammed N. Meah, Evangelos Tzolos, Jacek Kwiecinski, Mhairi Doris, Priscilla McElhinney, Alastair J. Moss, Philip D. Adamson, Amanda Hunter, Shirjel Alam, Anoop S. V. Shah, Tania Pawade, Chengjia Wang, Jonathan R. Weir-McCall, Giles Roditi, Edwin J. R. van Beek, Edward D. Nicol, Leslee J. Shaw, Daniel S. Berman, Piotr J. Slomka, Nicholas L. Mills, Marc R. Dweck, David E. Newby, Scott W. Murray, Damini Dey, Michelle C. Williams, Carter, Jessica [0000-0002-9015-3216], Tzolos, Evangelos [0000-0003-0038-043X], McElhinney, Priscilla [0000-0002-7642-6804], Moss, Alastair J [0000-0003-4123-2070], Adamson, Philip D [0000-0002-6177-956X], Alam, Shirjel [0000-0002-2099-612X], Wang, Chengjia [0000-0003-2345-7364], Weir-McCall, Jonathan R [0000-0001-5842-842X], Roditi, Giles [0000-0001-9393-7764], van Beek, Edwin JR [0000-0002-2777-5071], Berman, Daniel S [0000-0002-3793-9578], Slomka, Piotr J [0000-0002-6110-938X], Mills, Nicholas L [0000-0003-0533-7991], Dweck, Marc R [0000-0001-9847-5917], Newby, David E [0000-0001-7971-4628], Dey, Damini [0000-0003-2236-6970], Williams, Michelle C [0000-0003-3556-2428], and Apollo - University of Cambridge Repository

Subjects
Nonalcoholic Fatty Liver Disease, Radiology, Nuclear Medicine and imaging, Hepatosteatosis, Coronary Artery Disease, Cardiac, Plaque Quantification, CT, Original Research
Abstract

Hepatosteatosis was associated with coronary artery disease at CT, including an increased burden of low-attenuation plaque, but this was not independent of other cardiovascular risk factors. PURPOSE: To assess the association between nonalcoholic fatty liver disease (NAFLD) and quantitative atherosclerotic plaque at CT. MATERIALS AND METHODS: In this post hoc analysis of the prospective Scottish Computed Tomography of the HEART trial (November 2010 to September 2014), hepatosteatosis and coronary artery calcium score were measured at noncontrast CT. Presence of stenoses, visually assessed high-risk plaque, and quantitative plaque burden were assessed at coronary CT angiography. Multivariable models were constructed to assess the impact of hepatosteatosis and cardiovascular risk factors on coronary artery disease. RESULTS: Images from 1726 participants (mean age, 58 years ± 9 [SD]; 974 men) were included. Participants with hepatosteatosis (155 of 1726, 9%) had a higher body mass index, more hypertension and diabetes mellitus, and higher cardiovascular risk scores (P < .001 for all) compared with those without hepatosteatosis. They had increased coronary artery calcium scores (median, 43 Agatston units [AU] [interquartile range, 0-273] vs 19 AU [0-225], P = .046), more nonobstructive disease (48% vs 37%, P = .02), and higher low-attenuation plaque burden (5.11% [0-7.16] vs 4.07% [0-6.84], P = .04). However, these associations were not independent of cardiovascular risk factors. Over a median of 4.7 years, there was no evidence of a difference in myocardial infarction between those with and without hepatosteatosis (1.9% vs 2.4%, P = .92). CONCLUSION: Hepatosteatosis at CT was associated with an increased prevalence of coronary artery disease at CT, but this was not independent of the presence of cardiovascular risk factors.Keywords: CT, Cardiac, Nonalcoholic Fatty Liver Disease, Coronary Artery Disease, Hepatosteatosis, Plaque QuantificationClinical trial registration no. NCT01149590 Supplemental material is available for this article. © RSNA, 2022See also commentary by Abohashem and Blankstein in this issue.

Published
2022

37. Pericoronary adipose tissue attenuation, low-attenuation plaque burden and 5-year risk of myocardial infarction

Author

Kajetan Grodecki, Andrew Lin, Chengjia Wang, Nicholas L. Mills, Jacek Kwiecinski, Shirjel Alam, P. Adamson, Jonathan R. Weir-McCall, Priscilla McElhinney, E. J. R. Van Beek, Tania Pawade, Anoop S V Shah, Amanda Hunter, Leslee J. Shaw, Edward D. Nicol, Michelle A. Williams, Evangelos Tzolos, Piotr J. Slomka, David E. Newby, Mhairi Doris, F T Guadalupe, Sebastien Cadet, Damini Dey, A. Moss, D. Berman, M R Dweck, G. Roditi, Weir-McCall, Jonathan [0000-0001-5842-842X], and Apollo - University of Cambridge Repository

Subjects
pericoronary adipose tissue, medicine.medical_specialty, Computed Tomography Angiography, Myocardial Infarction, Adipose tissue, risk stratification, Coronary Artery Disease, Coronary Angiography, Myocardial Infarction/diagnostic imaging, Predictive Value of Tests, Internal medicine, medicine, Humans, Radiology, Nuclear Medicine and imaging, Myocardial infarction, noncalcified plaque burden, Aged, Coronary Angiography/methods, Computed Tomography Angiography/methods, Adipose Tissue/diagnostic imaging, business.industry, Attenuation, low-attenuation noncalcified plaque burden, Middle Aged, medicine.disease, Plaque, Atherosclerotic, Adipose Tissue, Cardiology, business, Cardiology and Cardiovascular Medicine, Coronary Artery Disease/diagnostic imaging
Abstract

Background: Pericoronary adipose tissue (PCAT) attenuation and low-attenuation noncalcified plaque (LAP) burden can both predict outcomes. Objectives: This study sought to assess the relative and additive values of PCAT attenuation and LAP to predict future risk of myocardial infarction. Methods: In a post hoc analysis of the multicenter SCOT-HEART (Scottish Computed Tomography of the Heart) trial, the authors investigated the relationships between the future risk of fatal or nonfatal myocardial infarction and PCAT attenuation measured from coronary computed tomography angiography (CTA) using multivariable Cox regression models including plaque burden, obstructive coronary disease, and cardiac risk score (incorporating age, sex, diabetes, smoking, hypertension, hyperlipidemia, and family history). Results: In 1,697 evaluable participants (age: 58 ± 10 years), there were 37 myocardial infarctions after a median follow-up of 4.7 years. Mean PCAT was −76 ± 8 HU and median LAP burden was 4.20% (IQR: 0%-6.86%). PCAT attenuation of the right coronary artery (RCA) was predictive of myocardial infarction (HR: 1.55; P = 0.017, per 1 SD increment) with an optimum threshold of −70.5 HU (HR: 2.45; P = 0.01). In multivariable analysis, adding PCAT-RCA of ≥−70.5 HU to an LAP burden of >4% (the optimum threshold for future myocardial infarction; HR: 4.87; P < 0.0001) led to improved prediction of future myocardial infarction (HR: 11.7; P < 0.0001). LAP burden showed higher area under the curve compared to PCAT attenuation for the prediction of myocardial infarction (AUC = 0.71 [95% CI: 0.62-0.80] vs AUC = 0.64 [95% CI: 0.54-0.74]; P < 0.001), with increased area under the curve when the 2 metrics are combined (AUC = 0.75 [95% CI: 0.65-0.85]; P = 0.037). Conclusion: Coronary CTA–defined LAP burden and PCAT attenuation have marked and complementary predictive value for the risk of fatal or nonfatal myocardial infarction.

Published
2022

38. Great debates in cardiac computed tomography: OPINION: 'Artificial intelligence and the future of cardiovascular CT - Managing expectation and challenging hype'

Author

Edward D. Nicol, Jonathan R. Weir-McCall, Leslee J. Shaw, and Eric Williamson

Subjects
Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine
Abstract

This manuscript has been written as a follow-up to the "AI/ML great debate" featured at the 2021 Society of Cardiovascular Computed Tomography (SCCT) Annual Scientific Meeting. In debate style, we highlighti the need for expectation management of AI/ML, debunking the hype around current AI techniques, and countering the argument that in its current day format AI/ML is the "silver bullet" for the interpretation of daily clinical CCTA practice.

Published
2022

39. Cardiopulmonary, functional, cognitive and mental health outcomes post COVID, across the range of severity of acute illness, in a physically active working age population

Author

Oliver O'Sullivan, David A Holdsworth, Peter Ladlow, Robert M Barker-Davies, Rebecca Chamley, Andrew Houston, Samantha May, Dominic Dewson, Daniel Mills, Kayleigh Pierce, James Mitchell, Cheng Xie, Edward Sellon, Jon Naylor, Joseph Mulae, Mark Cranley, Nick P Talbot, Oliver J Rider, Edward D Nicol, and Alexander N Bennett

Abstract

Objectives: To investigate cardiopulmonary, functional, cognitive, and mental health post-COVID-19 outcomes in a young, physically active working-age population, across the spectrum of acute COVID-19 severity. Methods: Observational cohort study of 4 groups; hospitalised, community illness with on-going symptoms (community-symptomatic), community illness now recovered (community-recovered) and controls. Participants underwent extensive clinical assessment involving cardiopulmonary imaging, submaximal and maximal exercise testing, pulmonary function, cognitive assessment, blood tests, electrocardiogram and questionnaires on mental health and physical function. Results: 113 participants (aged 39±9 and 86% male) were recruited into four groups, Hospitalised (n=35), community-symptomatic (n=34), community-recovered (n=18) and control (n=26), at 159±72days following acute illness. Hospitalized and community-symptomatic groups were older, with a higher body mass index, and worse mental health, fatigue, and quality of life scores. Hospitalised and community-symptomatic participants also performed less well on sub-maximal and maximal exercise testing. Hospitalised individuals had impaired ventilatory efficiency (higher VE/V̇CO2 slope), achieved less work at the anaerobic threshold and at peak than other groups and had a significantly reduced forced vital capacity. Clinically significant abnormal cardiopulmonary imaging findings were present in 6% of hospitalised participants. Those who recovered from COVID-19 had no significant differences when compared with controls.Conclusion: Recovered individuals who suffered mild-moderate COVID-19 do not differ from an age, sex and job-role matched control population. Individuals who were hospitalised or continue to suffer symptoms require a specific, comprehensive assessment prior to a return to full physical activity.

Published
2022

40. Following the evidence: The pre-eminent role of coronary CT angiography in 2021

Author

Todd C. Villines, Edward D. Nicol, and Gudrun Feuchtner

Subjects
medicine.medical_specialty, Computed Tomography Angiography, business.industry, Patient Selection, Clinical Decision-Making, Reproducibility of Results, Coronary ct angiography, Coronary Artery Disease, Coronary Angiography, Coronary computed tomography, Percutaneous Coronary Intervention, Treatment Outcome, Predictive Value of Tests, Humans, Medicine, Stents, Radiology, Nuclear Medicine and imaging, Radiology, Coronary Artery Bypass, Cardiology and Cardiovascular Medicine, business
Published
2021

41. Opportunities and challenges of implementing computed tomography fractional flow reserve into clinical practice

Author

Muhummad Sohaib Nazir, Tarun Mittal, Keith M. Channon, Jonathan R. Weir-McCall, Edward D. Nicol, Koen Nieman, Nazir, Muhummad Sohaib [0000-0003-2749-1033], Weir-McCall, Jonathan [0000-0001-5842-842X], Nicol, Edward D [0000-0001-9280-787X], and Apollo - University of Cambridge Repository

Subjects
Coronary angiography, medicine.medical_specialty, Computed Tomography Angiography, advanced cardiac imaging, Clinical Decision-Making, CAD, Computed tomography, Coronary Artery Disease, Fractional flow reserve, 030204 cardiovascular system & hematology, Coronary Angiography, Severity of Illness Index, Coronary artery disease, 03 medical and health sciences, 0302 clinical medicine, Resource (project management), Predictive Value of Tests, cardiac computer tomographic (CT) imaging, Humans, Medicine, 030212 general & internal medicine, Intensive care medicine, medicine.diagnostic_test, business.industry, chronic coronary disease, Models, Cardiovascular, Reproducibility of Results, Prognosis, medicine.disease, Coronary Vessels, Fractional Flow Reserve, Myocardial, Clinical Practice, Hydrodynamics, Radiographic Image Interpretation, Computer-Assisted, Functional significance, Cardiology and Cardiovascular Medicine, business
Abstract

CT-derived fractional flow reserve (CT-FFR) uses computational fluid dynamics to derive non-invasive FFR to determine the haemodynamic significance of coronary artery lesions. Studies have demonstrated good diagnostic accuracy of CT-FFR and reassuring short-term clinical outcome data.As a prerequisite, high-quality CT coronary angiography (CTCA) images are required with good heart rate control and pre-treatment with glyceryl trinitrate, which would otherwise render CTCA as unsuitable for CT-FFR. CT-FFR can determine the functional significance of CAD lesions, and there are supportive data for its use in clinical decision-making. However, the downstream impact on myocardial ischaemic burden or viability cannot be obtained.Several challenges remain with implementation of CT-FFR, including interpretation, training, availability, resource utilisation and funding. Further research is required to determine which cases should be considered for clinical CT-FFR analysis, with additional practical guidance on how to implement this emerging technique in clinical practice. Furthermore, long-term prognostic data are required before widespread clinical implementation of CT-FFR can be recommended.While there are several potential opportunities for CT-FFR, at present there remain important systemic and technical limitations and challenges that need to be overcome prior to routine integration of CT-FFR into clinical practice.

Published
2020

42. Low-Attenuation Noncalcified Plaque on Coronary Computed Tomography Angiography Predicts Myocardial Infarction

Author

Michelle C. Williams, Amanda Hunter, Giles Roditi, Christopher Murrills, Nicholas L. Mills, Shirjel Alam, Daniel S. Berman, Priscilla McElhinney, Sebastien Cadet, Edward D. Nicol, Mhairi K. Doris, David E. Newby, Jacek Kwiecinski, Michael Bonnici-Mallia, Chengjia Wang, Anoop S V Shah, Alastair J Moss, Philip D Adamson, Leslee J. Shaw, Marc R. Dweck, Edwin J R van Beek, Michelle S. D’Souza, Damini Dey, Piotr J. Slomka, Tania Pawade, and Jonathan R. Weir McCall

Subjects
Male, medicine.medical_specialty, Time Factors, Future risk, Computed tomography, Coronary stenosis, Coronary Angiography, Risk Assessment, plaque, atherosclerotic, Coronary artery disease, plaque, Predictive Value of Tests, Physiology (medical), Internal medicine, Original Research Articles, Medicine, Humans, Myocardial infarction, Angina, Stable, atheroscleroticcardiovascular diseases, Vascular Calcification, Computed tomography angiography, Aged, medicine.diagnostic_test, Coronary artery calcium score, business.industry, Coronary computed tomography angiography, Coronary Stenosis, Middle Aged, medicine.disease, Prognosis, cardiovascular diseases, myocardial infarction, Scotland, Heart Disease Risk Factors, Cardiology, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Female, atherosclerosis, Cardiology and Cardiovascular Medicine, business, computed tomography angiography, coronary artery disease
Abstract

Supplemental Digital Content is available in the text., Background: The future risk of myocardial infarction is commonly assessed using cardiovascular risk scores, coronary artery calcium score, or coronary artery stenosis severity. We assessed whether noncalcified low-attenuation plaque burden on coronary CT angiography (CCTA) might be a better predictor of the future risk of myocardial infarction. Methods: In a post hoc analysis of a multicenter randomized controlled trial of CCTA in patients with stable chest pain, we investigated the association between the future risk of fatal or nonfatal myocardial infarction and low-attenuation plaque burden (% plaque to vessel volume), cardiovascular risk score, coronary artery calcium score or obstructive coronary artery stenoses. Results: In 1769 patients (56% male; 58±10 years) followed up for a median 4.7 (interquartile interval, 4.0–5.7) years, low-attenuation plaque burden correlated weakly with cardiovascular risk score (r=0.34; P

Published
2020

43. Highlights of the fourteenth annual scientific meeting of the Society of Cardiovascular Computed Tomography

Author

Jonathon Leipsic, Brian B. Ghoshhajra, Suhny Abbara, Leslee J. Shaw, Andrew D. Choi, Jonathan R. Weir-McCall, Ron Blankstein, Edward D. Nicol, Kelley R. Branch, and Koen Nieman

Subjects
medicine.medical_specialty, Cardiac computed tomography, medicine.diagnostic_test, business.industry, Computed tomography, 030204 cardiovascular system & hematology, 030218 nuclear medicine & medical imaging, Clinical Practice, 03 medical and health sciences, 0302 clinical medicine, Medicine, Radiology, Nuclear Medicine and imaging, Medical physics, Cardiology and Cardiovascular Medicine, business
Abstract

The 14th Annual Scientific Meeting of the SCCT, held from July 11 to July 14 in Baltimore, MA, was attended by 830 attendees from 31 countries, with a program that included 45 sessions, and 26 exhibitors. This article summarizes several of the key themes and topics that were presented at this meeting, and provides an overview of the technical advances that are likely to impact future clinical practice in cardiovascular computed tomography.

Published
2020

44. Standardized reporting systems for computed tomography coronary angiography and calcium scoring: A real-world validation of CAD-RADS and CAC-DRS in patients with stable chest pain

Author

Ricardo C. Cury, Edwin J.R. van Beek, Edward D. Nicol, Philip D Adamson, Marc R. Dweck, Alastair J Moss, Shirjel Alam, Tania A. Pawade, Amanda Hunter, Giles Roditi, Christopher D. Maroules, Anoop S V Shah, David E. Newby, and Michelle C. Williams

Subjects
Male, Time Factors, Computed Tomography Angiography, Myocardial Infarction, Computed tomography, Coronary Artery Disease, 030204 cardiovascular system & hematology, Coronary Angiography, Chest pain, Severity of Illness Index, 030218 nuclear medicine & medical imaging, law.invention, Angina, Coronary artery disease, 0302 clinical medicine, Randomized controlled trial, Risk Factors, law, Medicine, Myocardial infarction, Randomized Controlled Trials as Topic, medicine.diagnostic_test, Incidence, Hazard ratio, Middle Aged, Prognosis, Radiology Information Systems, Cardiology, Female, medicine.symptom, Cardiology and Cardiovascular Medicine, medicine.medical_specialty, Risk Assessment, 03 medical and health sciences, Predictive Value of Tests, Internal medicine, Humans, Radiology, Nuclear Medicine and imaging, Angina, Stable, cardiovascular diseases, Vascular Calcification, Aged, Retrospective Studies, business.industry, Reproducibility of Results, nutritional and metabolic diseases, medicine.disease, Confidence interval, Scotland, business
Abstract

To assess the prognostic implications of standardized reporting systems for coronary computed tomography angiography (CCTA) and coronary artery calcium scores (CACS) in patients with stable chest pain.The Coronary Artery Disease Reporting And Data System (CAD-RADS) and Coronary Artery Calcium - Data and Reporting System (CAC-DRS) aim to improve communication of CACS and CCTA results, but its influence on prognostication is unknown.Images from 1769 patients who underwent CCTA as part of the Scottish Computed Tomography of the HEART (SCOT-HEART) multi-center randomized controlled trial were assessed. CACS were classified as CAC-DRS 0 to 3 based on Agatston scores. CCTA were classified as CAD-RADS 0 to 5 based on the most clinically relevant finding per patient. The primary outcome was the five-year events of fatal and non-fatal myocardial infarction.Patients had a mean age of 58 ± 10 years and 56% were male. CAC-DRS 0, 1, 2 and 3 occurred in 642 (36%), 510 (29%), 239 (14%) and 379 (21%) patients respectively. CAD-RADS 0, 1, 2, 3, 4A, 4B and 5 occurred in 622 (35%), 327 (18%), 211 (12%), 165 (9%), 221 (12%), 42 (2%) and 181 (10%) patients respectively. Patients classified as CAC-DRS 3 were at an increased risk of fatal or non-fatal myocardial infarction compared to CAC-DRS 0 patients (hazard ratio (HR) 9.41; 95% confidence interval (CI) 3.24, 27.31; p 0.001). Patients with higher CAD-RADS categories were at an increased risk of fatal or non-fatal myocardial infarction, with patients classified as CAD-RADS 4B at the highest risk compared to CAD-RADS 0 patients (HR 19.14; 95% CI 4.28, 85.53; p 0.001).Patients with higher CAC-DRS and CAD-RADS scores were at increased risk of subsequent fatal and non-fatal myocardial infarction. This confirms that the classification provides additional prognostic discrimination for future coronary heart disease events.

Published
2020

46. Prevalence and disease spectrum of extracoronary arterial abnormalities in spontaneous coronary artery dissection

Author

Salma Jebri, Joanne Wormleighton, Nilesh J. Samani, Robert Jackson, Deevia Kotecha, Nalin Natarajan, William Adair, Ciara Mahon, Patrick Chenu, Marcos García-Guimaraes, Javier Escaned, Diluka Premawardhana, Averachan Sajitha, Alexandre Persu, Abtehale Al-Hussaini, Christophe Beauloye, Patricia Van der Niepen, Fernando Macaya, David Adlam, Marilucy Lopez-Sublet, Gerry P McCann, Hannes Devos, M. Pappaccogli, Kandiyil Neghal, Ibtissem Radhouani, Frank Hammer, Nathan Chan, Edward D. Nicol, Kelly S Parke, Pierre-Yves Brillet, Clinical sciences, Clinical Pharmacology and Clinical Pharmacy, Nephrology, Supporting clinical sciences, Radiology, UCL - SSS/IREC/CARD - Pôle de recherche cardiovasculaire, UCL - (SLuc) Département cardiovasculaire, UCL - (SLuc) Service de radiologie, UCL - SSS/IREC/IMAG - Pôle d'imagerie médicale, and UCL - (SLuc) Centre de malformations vasculaires congénitales

Subjects
Male, Computed Tomography Angiography, Coronary Vessel Anomalies, Fibromuscular dysplasia, Magnetic resonance angiography, Sistema cardiovascular--Malalties, spontaneous coronary artery dissection, Prevalence, Fibromuscular Dysplasia, Original Investigation, medicine.diagnostic_test, Microfilament Proteins, imaging, Middle Aged, clinical relevance, Nephrology, Radiology Nuclear Medicine and imaging, cardiovascular system, Cardiology, Female, Cardiology and Cardiovascular Medicine, Comments, Adult, medicine.medical_specialty, Arterial tortuosity syndrome, extracoronary arterial abnormalities, Aneurysm, Aneurysm, Dissecting, Cor -- Malalties, Internal medicine, medicine, Humans, Online First, Clinical significance, Vascular Diseases, cardiovascular diseases, Aneurismes, Arterial dissection, business.industry, Research, Primary care physician, medicine.disease, United Kingdom, Aortic Dissection, SEVERITY, Case-Control Studies, business, Scad, Magnetic Resonance Angiography
Abstract

Key Points Question What is the prevalence of fibromuscular dysplasia, aneurysms, dissection, and tortuosity in extracoronary arteries of patients who developed a spontaneous coronary artery dissection (SCAD)? Findings In this case series including 173 patients with SCAD, using magnetic resonance angiography with blinded interpretation of the findings, 32% of the patients had fibromuscular dysplasia, 8% had aneurysms, and 2% had dissections; the prevalence of arterial tortuosity was similar in cases and controls. Extracoronary vascular events over a median 5-year follow-up were rare. Meaning The findings of this blinded analysis suggest that, in patients with SCAD, severe multivessel fibromuscular dysplasia, aneurysms, and dissections are infrequent and seldom associated with clinically evident vascular events., Importance Spontaneous coronary artery dissection (SCAD) has been associated with fibromuscular dysplasia (FMD) and other extracoronary arterial abnormalities. However, the prevalence, severity, and clinical relevance of these abnormalities remain unclear. Objective To assess the prevalence and spectrum of FMD and other extracoronary arterial abnormalities in patients with SCAD vs controls. Design, Setting, and Participants This case series included 173 patients with angiographically confirmed SCAD enrolled between January 1, 2015, and December 31, 2019. Imaging of extracoronary arterial beds was performed by magnetic resonance angiography (MRA). Forty-one healthy individuals were recruited to serve as controls for blinded interpretation of MRA findings. Patients were recruited from the UK national SCAD registry, which enrolls throughout the UK by referral from the primary care physician or patient self-referral through an online portal. Participants attended the national SCAD referral center for assessment and MRA. Exposures Both patients with SCAD and healthy controls underwent head-to-pelvis MRA (median time between SCAD event and MRA, 1 [IQR, 1-3] year). Main Outcome and Measures The diagnosis of FMD, arterial dissections, and aneurysms was established according to the International FMD Consensus. Arterial tortuosity was assessed both qualitatively (presence or absence of an S curve) and quantitatively (number of curves ≥45%; tortuosity index). Results Of the 173 patients with SCAD, 167 were women (96.5%); mean (SD) age at diagnosis was 44.5 (7.9) years. The prevalence of FMD was 31.8% (55 patients); 16 patients (29.1% of patients with FMD) had involvement of multiple vascular beds. Thirteen patients (7.5%) had extracoronary aneurysms and 3 patients (1.7%) had dissections. The prevalence and degree of arterial tortuosity were similar in patients and controls. In 43 patients imaged with both computed tomographic angiography and MRA, the identification of clinically significant remote arteriopathies was similar. Over a median 5-year follow-up, there were 2 noncardiovascular-associated deaths and 35 recurrent myocardial infarctions, but there were no primary extracoronary vascular events. Conclusions and Relevance In this case series with blinded analysis of patients with SCAD, severe multivessel FMD, aneurysms, and dissections were infrequent. The findings of this study suggest that, although brain-to-pelvis imaging allows detection of remote arteriopathies that may require follow-up, extracoronary vascular events appear to be rare., This case series examines the prevalence of fibromuscular dysplasia and other extracoronary events in patients who develop spontaneous coronary artery dissection.

Published
2022

47. Radiologist opinions regarding reporting incidental coronary and cardiac calcification on thoracic CT

Author

James Stirrup, Matthias Schmitt, Edward D. Nicol, J. Weir-McCall, Russell Bull, Aparna Deshpande, Bobby Agrawal, Deepa Gopalan, G. Morgan Hughes, A. Moss, G. Roditi, Michelle A. Williams, Ben Holloway, James Shambrook, Williams, Michelle C [0000-0003-3556-2428], and Apollo - University of Cambridge Repository

Subjects
medicine.medical_specialty, 4003 Biomedical Engineering, business.industry, Prevention, 32 Biomedical and Clinical Sciences, General Medicine, medicine.disease, Cardiovascular, Heart Disease, 3201 Cardiovascular Medicine and Haematology, cardiovascular system, Medicine, Thoracic ct, Biomedical Imaging, Radiology, Nuclear Medicine and imaging, Radiology, Cardiology and Cardiovascular Medicine, business, 3202 Clinical Sciences, Heart Disease - Coronary Heart Disease, Calcification, 40 Engineering
Abstract

Objectives: Coronary and cardiac calcification are frequent incidental findings on non-gated thoracic computed tomography (CT). However, radiologist opinions and practices regarding the reporting of incidental calcification are poorly understood. Methods: UK radiologists were invited to complete this online survey, organised by the British Society of Cardiovascular Imaging (BSCI). Questions included anonymous information on subspecialty, level of training and reporting practices for incidental coronary artery, aortic valve, mitral and thoracic aorta calcification. Results: The survey was completed by 200 respondents: 10% trainees and 90% consultants. Calcification was not reported by 11% for the coronary arteries, 22% for the aortic valve, 35% for the mitral valve and 37% for the thoracic aorta. Those who did not subspecialise in cardiac imaging were less likely to report coronary artery calcification (p = 0.005), aortic valve calcification (p = 0.001) or mitral valve calcification (p = 0.008), but there was no difference in the reporting of thoracic aorta calcification. Those who did not subspecialise in cardiac imaging were also less likely to provide management recommendations for coronary artery calcification (p < 0.001) or recommend echocardiography for aortic valve calcification (p < 0.001), but there was no difference for mitral valve or thoracic aorta recommendations. Conclusion: Incidental coronary artery, valvular and aorta calcification are frequently not reported on thoracic CT and there are differences in reporting practices based on subspeciality. Advances in knowledge: On routine thoracic CT, 11% of radiologists do not report coronary artery calcification. Radiologist reporting practices vary depending on subspeciality but not level of training.

Published
2022

48. CT multivessel aggregate stenosis score: A novel point-of-care tool for predicting major adverse cardiac events

Author

Edd Maclean, Ciara Mahon, Joban Sehmi, Gajen Kanaganayagam, Tan Thuan Ngee, and Edward D. Nicol

Subjects
Computed Tomography Angiography, Point-of-Care Systems, Constriction, Pathologic, Coronary Artery Disease, Coronary Angiography, Prognosis, Risk Assessment, Severity of Illness Index, Plaque, Atherosclerotic, Predictive Value of Tests, Risk Factors, Humans, Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine, Tomography, X-Ray Computed
Abstract

We evaluated the utility of a novel 15-point multivessel aggregate stenosis (MVAS) score for predicting major adverse cardiac events (MACE) in low-risk patients with suspected ischaemic symptoms undergoing CTCA. Prognostic performance was compared with the Coronary Artery Disease Reporting and Data System (CAD-RADS) classification and the 16-point Segment Involvement Score (SIS).772 consecutive patients underwent CTCA and coronary artery calcification scoring (CACS) from 2010 to 2015. Coronary artery disease severity was calculated according to CAD-RADS class (0-5 ​± ​vulnerability modifier), the SIS (0-16), and an MVAS score (0-15) based on the aggregate stenosis severity in all 4 coronary vessels (maximum 12 points) plus the presence of any high-risk plaque features (additional 3 points). 52 patients were referred directly for coronary angiography based on CTCA findings and were excluded; the remainder were followed-up for 64.6 ​± ​19.1 months.54 ​MACE were observed in 720 patients (7.5%); MACE patients had higher CAD-RADS class (3.92 ​± ​0.7 vs 0.91 ​± ​1.2, p ​ ​0.0001), SIS (4.59 ​± ​2.7 vs 0.79 ​± ​1.2, p ​ ​0.0001), and MVAS scores (10.1 ​± ​1.7 vs 1.7 ​± ​2.1, p ​ ​0.0001). Adjusted Cox proportional hazards analysis identified CAD-RADS class (HR 2.96 (2.2-4), p ​ ​0.0001), SIS (HR 1.29 (1.2-1.4, p ​ ​0.0001), and MVAS score (HR 1.82 (1.6-2.1), p ​ ​0.0001) as predictors of MACE. Adjusted receiver operating characteristic (ROC) analysis found MVAS a more powerful predictor of MACE than CAD-RADS and SIS (AUC: 0.92 vs 0.84 vs 0.83, p ​= ​0.018).CAD-RADS and SIS are reliable predictors of MACE, and the MVAS score provided incremental prognostic data. MVAS may potentiate risk stratification, particularly in institutions without advanced plaque analysis software.

Published
2021

49. Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19

Author

D A Holdsworth, R M Barker-Davies, R R Chamley, O O’Sullivan, P Ladlow, S May, A D Houston, J Mulae, C Xie, M Cranley, E Sellon, J Naylor, M Halle, G Parati, C Davos, O J Rider, A B Bennett, and E D Nicol

Subjects
General Medicine
Abstract

ObjectivePost-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings.Methods113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease.Results7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O226.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope 2slope ConclusionsIn a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Published
2022

50. Comprehensive clinical assessment identifies specific neurocognitive deficits in working-age patients with long-COVID

Author

David A. Holdsworth, Rebecca Chamley, Rob Barker-Davies, Oliver O’Sullivan, Peter Ladlow, James L. Mitchell, Dominic Dewson, Daniel Mills, Samantha L. J. May, Mark Cranley, Cheng Xie, Edward Sellon, Joseph Mulae, Jon Naylor, Betty Raman, Nick P. Talbot, Oliver J. Rider, Alexander N. Bennett, and Edward D. Nicol

Subjects
Adult, Male, Multidisciplinary, Post-Acute COVID-19 Syndrome, Acute Disease, COVID-19, Humans, Female, Lung, Fatigue
Abstract

IntroductionThere have been more than 425 million COVID-19 infections worldwide. Post-COVID illness has become a common, disabling complication of this infection. Therefore, it presents a significant challenge to global public health and economic activity.MethodsComprehensive clinical assessment (symptoms, WHO performance status, cognitive testing, CPET, lung function, high-resolution CT chest, CT pulmonary angiogram and cardiac MRI) of previously well, working-age adults in full-time employment was conducted to identify physical and neurocognitive deficits in those with severe or prolonged COVID-19 illness.Results205 consecutive patients, age 39 (IQR30.0–46.7) years, 84% male, were assessed 24 (IQR17.1–34.0) weeks after acute illness. 69% reported ≥3 ongoing symptoms. Shortness of breath (61%), fatigue (54%) and cognitive problems (47%) were the most frequent symptoms, 17% met criteria for anxiety and 24% depression. 67% remained below pre-COVID performance status at 24 weeks. One third of lung function tests were abnormal, (reduced lung volume and transfer factor, and obstructive spirometry). HRCT lung was clinically indicated in ConclusionDespite low rates of residual cardiopulmonary pathology, in this cohort, with low rates of premorbid illness, there is a high burden of symptoms and failure to regain pre-COVID performance 6-months after acute illness. Cognitive assessment identified a specific deficit of the same magnitude as intoxication at the UK drink driving limit or the deterioration expected with 10 years ageing, which appears to contribute significantly to the symptomatology of long-COVID.

Published
2021

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