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The predictive value of computed tomography calcium scores: a comparison with quantitative volumetric intravascular ultrasound
Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129 Evolution of nonculprit complex coronary lesions RA Costantini, JM Telayna, FI Graziano Hospital Universitario Austral, Pilar, Argentina Introduction: In the diffuse nature of coronary atherosclerosis, plaque instability might be expected to develop in a multifocal pattern, resulting in multiple complex, unstable plaques in anatomically remote locations; any one of these lesions might progress to total occlusions of a vessel and emerge as the cause of an acute coronary syndrome (ACS). It is assumed that severity or complexity of nonculprit complex lesions might be changed with the time in accordance with their different clinical outcomes for the pharmacology treatment. Objective: To determine the evolution of novo nonculprit complex lesions defined as causing at least 50% stenosis and having 2 or more of the following morphological features: (a) ulceration, (b) irregularities or creaneted edges, (c) sharp stenosis angulation in the wall, (d) endoluminal defects compatible with thrombus, (e) long lesions above 25 mm, or (f) true or type I bifurcations vs novo nonculprit lesion noncomplex in patients who underwent interventions percutaneous coronary intervention (PCI) of another vessel for ACS. Methods and materials: Since May 2000 to September 2007, 115 patients (pts) with PCI in a major coronary vessel for a culprit lesion in a different territory were tested in 44 pts with nonculprit complex lesion (group A) vs 71 pts with nonculprit noncomplex lesion nonrevascularized in the index procedure. The population presented, respectively, the following: female sex, 8 (18%) vs 14 (20%); diabetes, 8 (18%) vs 13 (18%); 3-vessel diseases 15 (34%) vs 23 (32%); ACS ST, 20 (45%) vs 35 (49%); ACS non-ST, 24 (54%) vs 36 (51%); and use of IIb/IIIa, 19 (43%) vs 19 (27%). Results: The clinical success was (technical success without MACE, intrahospital) 42 (95%) vs 67 (94%). In the follow-up, a new revascularization procedure was necessary for angina or ischemia guided in 31% (13/42) in group A vs 10% (7/67) in group B in an average time of 2.8 month (P=.01). The revascularization was for PCI in 10 (24%)/6 (9%), and bypass, 3 (7%)/1 (1.5%), group A and B, respectively. Conclusions: The patients who needed more revascularizations were those who had nonculprit complex lesions in another territory different from culprit lesion. The present observation identifies a subgroup of patients at increased risk of recurrent ischemia and new revascularizations. doi:10.1016/j.carrev.2008.02.071
The predictive value of computed tomography calcium scores: a comparison with quantitative volumetric intravascular ultrasound T Okabe a, GS Mintz b, WG Weigold a, R Roswell a, S Joshi a, SY Lee a, B Lee a, P Roy a, DH Steinberg a, TL Pinto Slottow a, R Torguson a, KA Smith a, Z Xue a, LF Satler a, KM Kent a, AD Pichard a, NJ Weissman a, J Lindsay a, R Waksman a a Washington Hospital Center, Washington, DC, USA b Cardiovascular Research Foundation, New York, NY, USA Background: Coronary artery calcium scoring (CACS) by cardiac computed tomography is used to risk-stratify patients for coronary events. Methods: We examined the relationship between CACS and intravascular ultrasound (IVUS) quantification in 43 patients undergoing CACS 18±23 days before IVUS. Volumetric IVUS analysis included external elastic membrane, lumen and plaque and media areas, volumes, and plaque burden. Coronary artery calcium scoring used the Agatson-130 protocol. Results: There were 106 calcified and 17 noncalcified lesions detected by IVUS. Eighty-five of the IVUS-calcified lesions (80%) were detected by the CACS protocol, but 38 lesions (36%) were missed entirely. Fourteen (50%) of 28 of the lesions with an IVUS arc of calcium below the 25th percentile (51.4°) were detected by CACS vs 91% of lesions with an IVUS arc of calcium above 51.4° (Pb.05). Similarly, only 58% (21/36) lesions 3 mm or less in length were detected vs 91% of lesions above 3 mm in length (Pb.05). We divided IVUScalcified lesions into 2 categories (calcium score ≤10 and N10). Mean plaque
123
burden, calcified length, and arc of calcium increased significantly; and minimum lumen area decreased with increasing CACS. There was the same tendency in culprit and nonculprit calcified lesions, respectively. Conclusion: This study suggested that a CACS could evaluate coronary calcium burden noninvasively through the accurate estimation of calcium arc and length, which leads to prediction of its prognosis Multivariate generalized liner analysis Regression coefficient IVUS length of calcification IVUS arc of calcification Minimum luminal area Plaque burden
95% Confidence interval
P
8.718
4.668-12.77
b.001
2.769
1.419-4.119
b.001
1.475 −129
−12.6 to 15.60 −583 to 324.6
.8 .6
doi:10.1016/j.carrev.2008.02.072
Safety and efficacy of direct stenting compared with distal protection device in saphenous vein graft lesions T Okabe, R Torguson, P Roy, DH Steinberg, TL Pinto Slottow, KA Smith, Z Xue, LF Satler, KM Kent, AD Pichard, J Lindsay, R Waksman Washington Hospital Center, Washington, DC, USA Background: Although direct stenting (DS) can result in less embolization, its effect in saphenous vein graft (SVG) remains to be unknown compared with distal protection device (DPD). Methods: Overall, 226 nonacute myocardial infarction patients underwent SVG intervention—112 patients with 154 lesions treated with DPD and 114 patients with 142 lesions by DS without DPD. The major adverse cardiovascular events (MACE) in hospital and at 30 days after procedure were compared between 2 groups. Results: Baseline characteristics were comparable between groups, except a higher frequency of worsening angina was in DPD group (16.1% vs 6.2%, P=.018), but there was no difference in lesion types except for more restenotic lesions in DS (5.8% vs 12.7%, P=.041). Drug-eluting stent deployment was similar. Clinical success was achieved in 99.1% of patients overall. The frequency of creatine kinase–MB (CK-MB) rise more than 5 times upper limit of normal (ULN) after procedure did not differ despite the higher percentage of CK-MB more than 2 times ULN in DPD (16.1% vs 7.3%, P=.042). There were no differences in MACE in hospital and at 30 days (Table 1). By multivariate logistic regression analysis, DPD was not associated with CK-MB rise more than 2 times ULN (odds ratio 2.06, 95% confidence interval 0.79-5.38, P=.141). Conclusion: Both DPD and DS in SVG offered good clinical results. Direct stenting should be considered as an alternative treatment modality to angioplasty with DPD for SVG lesion as it demonstrates low postprocedural CK-MB elevation and is a less cumbersome technique.
Table 1 In-hospital and 30-day outcomes Parameter (%) Inhospital Q-wave myocardial infarction 30 d MACE Target vessel revascularization Death Q-wave myocardial infarction doi:10.1016/j.carrev.2008.02.073
DPD (n=112)
DS (n=114)
P
1 (0.9)
0
1.0
5 (4.5) 4 (3.6) 2 (1.8) 0
6 (5.3) 1 (0.9) 4 (3.5) 1 (0.9)
.8 .2 .7 1.0
The predictive value of computed tomography calcium scores: a comparison with quantitative volumetric intravascular ultrasound T Okabe a, GS Mintz b, WG Weigold a, R Roswell a, S Joshi a, SY Lee a, B Lee a, P Roy a, DH Steinberg a, TL Pinto Slottow a, R Torguson a, KA Smith a, Z Xue a, LF Satler a, KM Kent a, AD Pichard a, NJ Weissman a, J Lindsay a, R Waksman a a Washington Hospital Center, Washington, DC, USA b Cardiovascular Research Foundation, New York, NY, USA Background: Coronary artery calcium scoring (CACS) by cardiac computed tomography is used to risk-stratify patients for coronary events. Methods: We examined the relationship between CACS and intravascular ultrasound (IVUS) quantification in 43 patients undergoing CACS 18±23 days before IVUS. Volumetric IVUS analysis included external elastic membrane, lumen and plaque and media areas, volumes, and plaque burden. Coronary artery calcium scoring used the Agatson-130 protocol. Results: There were 106 calcified and 17 noncalcified lesions detected by IVUS. Eighty-five of the IVUS-calcified lesions (80%) were detected by the CACS protocol, but 38 lesions (36%) were missed entirely. Fourteen (50%) of 28 of the lesions with an IVUS arc of calcium below the 25th percentile (51.4°) were detected by CACS vs 91% of lesions with an IVUS arc of calcium above 51.4° (Pb.05). Similarly, only 58% (21/36) lesions 3 mm or less in length were detected vs 91% of lesions above 3 mm in length (Pb.05). We divided IVUScalcified lesions into 2 categories (calcium score ≤10 and N10). Mean plaque
123
burden, calcified length, and arc of calcium increased significantly; and minimum lumen area decreased with increasing CACS. There was the same tendency in culprit and nonculprit calcified lesions, respectively. Conclusion: This study suggested that a CACS could evaluate coronary calcium burden noninvasively through the accurate estimation of calcium arc and length, which leads to prediction of its prognosis Multivariate generalized liner analysis Regression coefficient IVUS length of calcification IVUS arc of calcification Minimum luminal area Plaque burden
95% Confidence interval
P
8.718
4.668-12.77
b.001
2.769
1.419-4.119
b.001
1.475 −129
−12.6 to 15.60 −583 to 324.6
.8 .6
doi:10.1016/j.carrev.2008.02.072
Safety and efficacy of direct stenting compared with distal protection device in saphenous vein graft lesions T Okabe, R Torguson, P Roy, DH Steinberg, TL Pinto Slottow, KA Smith, Z Xue, LF Satler, KM Kent, AD Pichard, J Lindsay, R Waksman Washington Hospital Center, Washington, DC, USA Background: Although direct stenting (DS) can result in less embolization, its effect in saphenous vein graft (SVG) remains to be unknown compared with distal protection device (DPD). Methods: Overall, 226 nonacute myocardial infarction patients underwent SVG intervention—112 patients with 154 lesions treated with DPD and 114 patients with 142 lesions by DS without DPD. The major adverse cardiovascular events (MACE) in hospital and at 30 days after procedure were compared between 2 groups. Results: Baseline characteristics were comparable between groups, except a higher frequency of worsening angina was in DPD group (16.1% vs 6.2%, P=.018), but there was no difference in lesion types except for more restenotic lesions in DS (5.8% vs 12.7%, P=.041). Drug-eluting stent deployment was similar. Clinical success was achieved in 99.1% of patients overall. The frequency of creatine kinase–MB (CK-MB) rise more than 5 times upper limit of normal (ULN) after procedure did not differ despite the higher percentage of CK-MB more than 2 times ULN in DPD (16.1% vs 7.3%, P=.042). There were no differences in MACE in hospital and at 30 days (Table 1). By multivariate logistic regression analysis, DPD was not associated with CK-MB rise more than 2 times ULN (odds ratio 2.06, 95% confidence interval 0.79-5.38, P=.141). Conclusion: Both DPD and DS in SVG offered good clinical results. Direct stenting should be considered as an alternative treatment modality to angioplasty with DPD for SVG lesion as it demonstrates low postprocedural CK-MB elevation and is a less cumbersome technique.
Table 1 In-hospital and 30-day outcomes Parameter (%) Inhospital Q-wave myocardial infarction 30 d MACE Target vessel revascularization Death Q-wave myocardial infarction doi:10.1016/j.carrev.2008.02.073
DPD (n=112)
DS (n=114)
P
1 (0.9)
0
1.0
5 (4.5) 4 (3.6) 2 (1.8) 0
6 (5.3) 1 (0.9) 4 (3.5) 1 (0.9)
.8 .2 .7 1.0