Bjorn Flygenring

Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy

OBJECTIVES We sought to assess the occurrence and clinical significance of stroke and peripheral arterial embolizations at non-central nervous system sites in a large, community-based cohort with hypertrophic cardiomyopathy (HCM). BACKGROUND Such vascular events are insufficiently appreciated complications of HCM for which there is limited information on occurrence, clinical profile and determinants. METHODS We assessed the clinical features of patients with stroke and other peripheral vascular events in a consecutive group of patients with HCM from four regional cohorts not subject to significant tertiary referral bias. RESULTS Of the 900 patients, 51 (6%) patients experienced stroke or other vascular events over 7 +/- 7 years, including 44 patients with stroke; 21 (41%) of these 51 patients died or were permanently disabled. The overall incidence was 0.8%/year and 1.9% for patients >60 years old. Age at first event ranged from 29 to 86 years (mean 61 +/- 14 years). Most (n = 37; 72%) events occurred in those >50 years, although 14 (28%) younger patients (< or = 50 years) also had events. Multivariate analysis showed stroke and other peripheral vascular events to be independently associated with congestive symptoms and advanced age, as well as with atrial fibrillation (in 45 [88%] of 51 patients), at the initial evaluation. The cumulative incidence of these events among patients with atrial fibrillation was significantly higher in non-anticoagulated patients as compared with patients receiving warfarin (31% vs. 18%; p < 0.05). CONCLUSIONS Stroke and peripheral embolizations showed a 6% prevalence rate and an incidence of 0.8%/year in a large, unselected HCM group. These profound complications of HCM, which may lead to disability and death, were substantially more common in the elderly, occurred almost exclusively in patients with paroxysmal or chronic atrial fibrillation and appeared to be reduced in frequency by anticoagulation.

Clinical utility of coronary CT angiography: coronary stenosis detection and prognosis in ambulatory patients.

Introduction: Multislice CT coronary angiography (MSCTA) accurately detects stenosis in patients undergoing coronary arteriography, but its accuracy in clinical outpatients is less certain. This study retrospectively analyzed MSCTA performance in a large outpatient cohort and examined 6‐month clinical follow‐up in those without invasive CA. Methods: Patients underwent MSCTA for clinical indications including symptoms or noninvasive results being either equivocal or suspected as incorrect by referring clinicians. Standard 16‐slice CT scanner techniques were used, and results were analyzed on the basis of both patient and vessel. Patients were treated medically or sent to invasive angiography on the basis of MSCTA results and judgment of referring clinicians. All invasive angiograms were analyzed using quantitative coronary angiography. Six‐month clinical follow‐up was determined in patients without CA. Results: One thousand fifty‐three consecutive patients were referred for MSCTA, resulting in 994 interpretable scans. Mean age was 58 ± 13 years, 55% were male, 50% had prior noninvasive testing, and 90% had symptoms. Invasive angiography was performed in 160 patients, with significant stenoses present in 69%. MSCTA demonstrated 87% and 89% accuracy by patient‐ and vessel‐based analysis, respectively, and was most accurate in the left main and right coronary arteries. Only two patients not referred for angiography had signficant stenosis in those undergoing 6‐month follow‐up. Conclusions: MSCTA accurately detects obstructive coronary stenosis in clinical patients with possible cardiac symptoms, and effectively triages them for invasive angiography. Negative results are highly accurate in ruling out obstructive disease. Six‐month prognosis is excellent in patients without significant disease determined by MSCT.

Identification of unexpected nonatherosclerotic cardiovascular disease with coronary CT angiography.

OBJECTIVES The aim of this study was to assess, in a general cardiology cohort screened for obstructive coronary artery disease (CAD), the effectiveness and frequency with which multidetector computed tomography (MDCT) angiography unexpectedly imaged and identified other nonatherosclerotic cardiovascular diseases. BACKGROUND MDCT angiography is a novel imaging strategy employed primarily to diagnose CAD that, in the course of these studies, can also potentially identify other important but previously unrecognized cardiovascular abnormalities. METHODS Consecutive 64-slice MDCT angiography studies were obtained in 4,543 patients with suspected atherosclerotic CAD at the Minneapolis Heart Institute, over a 29-month period (2005 to 2007). RESULTS Nonatherosclerotic-related cardiovascular abnormalities judged to be of potential clinical relevance were identified in 201 patients (4.4%). In 50 of these patients (1.1% of 4,543) the abnormality was previously unrecognized despite other imaging studies performed in 40%. Most common among the 50 patients were: congenital coronary artery anomalies (38%; largely right coronary artery from the left aortic sinus); ascending aortic aneurysms > or = 45 mm (22%); hypertrophic cardiomyopathy with apical left ventricular (LV) wall thickening (14%); valvular heart diseases (8%), congenital heart diseases, including ventricular septal defect (6%); pulmonary embolus (6%); as well as LV noncompaction, left atrial myxoma, and LV apical aneurysm (2% each). As a consequence of MDCT angiography findings, new management strategies were instituted in 15 of 50 patients (30%), including surgical correction of coronary artery anomalies of wrong sinus origin, ascending aneurysm graft repair, thrombolytic therapy for pulmonary embolism, and myxoma resection. CONCLUSIONS Approximately 1% of patients undergoing MDCT angiography for suspicion of CAD proved to have otherwise unsuspected, but clinically relevant, cardiovascular abnormalities unrelated to coronary atherosclerosis. Almost one-third of these patients had cardiovascular diseases with major clinical implications for subsequent therapy. These findings underscore the value of MDCT angiography and the importance of careful assessment of scans for the recognition of a variety of cardiovascular abnormalities.

Multidetector CT coronary angiography for patient triage to invasive coronary angiography: Performance and cost in ambulatory patients with equivocal or suspected inaccurate noninvasive stress tests†

Background: Multidetector‐CT angiography (MDCTA) differs from noninvasive stress tests by directly imaging coronary anatomy. The utility of MDCTA for invasive triage is undefined however. We evaluated MDCTA triage to invasive coronary angiography in outpatients with indeterminate or suspected inaccurate stress tests, and estimated cost savings by MDCTA in this role. Methods: Consecutive MDCTA patients were retrospectively compared with noninvasive stress tests if performed within 6 months of MDCTA. Twelve‐month clinical follow up was obtained for patients not undergoing invasive angiography, and cost using MDCTA for triage to invasive coronary angiography was calculated. Results: MDCTA was performed in 385 patients who had noninvasive stress testing. Stress tests include included treadmill (n = 37), stress echo (n = 178), and nuclear perfusion imaging (n = 170). Invasive angiography was performed in 57 (14.8%). MDCTA compared to CA showed positive and negative predictive values of 94%/100% respectively for lesions found by invasive QCA. Stress testing compared to MDCTA showed positive/negative predictive values of 100%/67% for treadmill exercise, 60%/54% for stress echo, and 59%/55% of nuclear perfusion examinations respectively. One year clinical follow up in 314 patients showed no coronary events in 98% (309) of patients. Triage to invasive angiography by MDCTA showed a 4‐fold cost reduction. Conclusions: MDCTA shows excellent performance as a triage for invasive angiography in patients with stress tests that are equivocal or thought inaccurate. A negative CTA confers good 12‐month prognosis. Substantial cost savings may accrue using MDCTA in this triage role.

Epithelioid Hemangioendothelioma of the Thoracic Aorta Resulting in Aortic Obstruction and Congestive Heart Failure

A54-year-old white woman was referred for cardiac consultation because of increased dyspnea with exertion and leg pain. The patient’s past medical history was significant for smoking and recent onset of hypertension. On physical examination, she was found to have a blood pressure of 180/90 mm Hg and a heart rate of 110 bpm. The lungs were clear to auscultation. The carotid upstrokes were bounding, and there were bilateral carotid bruits. The central venous pressure was not elevated. The cardiac examination was significant for a loud, harsh systolic murmur (II to III/VI) across the precordium with radiation to the back. There was a left ventricular lift and a third heart sound. The abdominal examination was normal, and stool guaiac was negative. There was no peripheral …

Multidetector CT coronary angiography: Where we are, and where we are going…

Coronary artery imaging has undergone major advances in recent years, the most significant being the advent of multidetector CT angiography (MDCTA). CT scanners with multiple detector rows, increased temporal and spatial resolution, and with powerful reconstruction and analysis software have enabled noninvasive coronary artery imaging to a degree never before possible. MDCTA not only allows accurate visualization and semiquantitation of coronary artery lumen stenoses [1], but it also provides important information about nonobstructive atherosclerotic plaque in the coronary artery wall [2]. While current 64-detector CT technology lacks sufficient spatial and temporal resolution to replace conventional diagnostic coronary angiography, it is nevertheless emerging as a valuable clinical adjunct [3]. This discussion first reviews the technical aspects of performing MDCTA and then focuses on patient selection, information currently available from MDCTA imaging, how this information is used clinically, and what the future may hold for MDCTA.