Outcomes of anatomical vs. functional testing for coronary artery disease : Lessons from the major trials.
- 作者列表："Karády J","Taron J","Kammerlander AA","Hoffmann U
:Management of patients presenting with suspected stable coronary artery disease (CAD) are challenging because estimation of pretest probability for obstructive CAD remains difficult. In addition, identification of those who benefit from coronary revascularization remains ineffective regardless of the wide array of noninvasive testing alternatives available. Functional testing, which has long been considered to be the test of choice to risk stratify these patients, shows modest agreement with CAD severity detected by invasive coronary angiography and has been reported to be ineffective in settings of low prevalence of obstructive CAD. A growing body of evidence demonstrates the excellent diagnostic accuracy as well as prognostic value of coronary computed tomography (CT) angiography especially in conjunction with noninvasive fractional flow reserve (FFR) testing, challenging the primary role of functional testing especially in patients without prior or known CAD. Landmark trials, including the Prospective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) and Scottish Computed Tomography of the Heart (SCOT-HEART), have contributed to a better understanding of how coronary CT angiography may play a role in more efficient management and even improved health outcomes. The emerging role of coronary CT has been acknowledged by the 2019 Guidelines of the European Society of Cardiology recommending the use of CT as a first-line tool for the evaluation of patients with stable chest pain with a class I, level of evidence B recommendation. The purpose of this article is to provide an overview on existing evidence, clinical implication, limitations of available data, and remaining questions to be answered by future research.
: 对疑似稳定型冠状动脉疾病 (CAD) 患者的管理具有挑战性，因为阻塞性CAD的预测试概率的估计仍然困难。此外，对那些受益于冠状动脉血运重建的患者的鉴定仍然是无效的，而不管现有的各种无创检测替代方法。长期以来，功能测试一直被认为是对这些患者进行风险分层的首选测试，显示出与侵入性冠状动脉造影所检测到的CAD严重程度的适度一致性，并且据报道在阻塞性CAD低患病率的情况下是无效的。越来越多的证据证明了冠状动脉计算机断层扫描 (CT) 血管造影的极好的诊断准确性以及预后价值，特别是与无创血流储备分数 (FFR) 测试相结合，挑战了功能测试的主要作用，特别是在没有既往或已知CAD的患者中。里程碑式的试验，包括用于评估胸痛的前瞻性多中心成像研究 (PROMISE) 和苏格兰心脏计算机断层扫描 (SCOT-Heart)，有助于更好地理解冠状动脉CT血管造影如何在更有效的管理甚至改善健康结局中发挥作用.冠状动脉CT的新兴作用已得到欧洲心脏病学会2019指南的认可，该指南建议使用CT作为一线工具，以I级证据水平B推荐评估稳定型胸痛患者.本文的目的是概述现有证据，临床意义，现有数据的局限性以及未来研究要回答的剩余问题。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.