Dragan Tavciovski

The Additive Diagnostic Role of Coronary Flow Reserve in Noninvasive Evaluation of Coronary Stenosis on Left Descending Artery Previously Detected by Multislice Computed Tomography

Purpose: Multislice computed coronary angiography (MSCT) provides valuable morphological information about coronary artery disease, but precise quantification of coronary stenosis remains difficult. Transthoracic color Doppler echocardiography (TDE) gives a new insight into the functional significance of coronary luminal narrowing. We have tried to assess the additive value of coronary flow reserve (CFR) determined by TDE over MSCT in prediction of a significant stenosis on the left anterior descending artery (LAD) using the invasive coronary angiography (ICA) as a reference method. Methods: This prospective study included 63 patients in stable cardiac status with previously detected atherosclerotic lesions on LAD by MSCT. CFR assessment by TDE with adenosine infusion was obtained to all patients (feasibility was 96.92%). CFR was determined as ratio between the peak diastolic flow velocity during adenosine infusion and at basal condition, a cutoff value indicating significant stenosis was <2. ICA was preformed to all patients 24–48 hours after CFR. Results: MSCT had sensitivity of 86.36%, specificity 53.66%, positive predictive value 50.00%, negative predictive value 88.00%, and diagnostic accuracy of 65.07% in detection of significant LAD stenosis. CFR had sensitivity 81.81%, specificity 97.06%, positive predictive value 94.74%, negative predictive value 89.19%, and diagnostic accuracy of 91.07%. When the results of both methods were agreed diagnostic accuracy was improved to 92.72%. Conclusion: Additional assessment of CFR by TDE increase diagnostic accuracy of MSCT angiography in detection of significant coronary artery lesions.

Forearm Approach for Percutaneous Coronary Procedures

This article gives contemporary review on the forearm approach for percutaneous diagnostic and interventional coronary procedures. Advantages and disadvantages as well as practical issues and current controversies regarding both radial and ulnar artery approach are discussed throughout the paper. Having in mind advantages of forearm approach in terms of safety and comfort over the traditional femoral approach, as well as the rapid development of invasive technology in the past years, it will probably become the default vascular approach for all percutaneous coronary procedures in the near future.

Medical treatments in aortic stenosis: Role of statins and angiotensin-converting enzyme inhibitors

CALCIFIC AROTIC STENOSIS AND ATHEROSCLEROSIS: Aortic stenosis is the most frequent valvular heart disease in western world and its incidence continues to rise. Aortic sclerosis is the first characteristic lesion of the cusps, which is today considered a process similar to atherosclerosis. The progression of the disease is an active process leading to forming of bone matrix and heavily calcified stiff cusps by inflammatory cells and osteopontin. Aortic stenosis is a chronic, progressive disease which can remain asymptomatic for a long time even in the presence of severe aortic stenosis. MEDICAL TREATMENT FOR AORTIC STENOSIS: The need for alternative to aortic valve surgery is highlighted by increasing longevity of the population and new therapeutic strategies to limit disease progression are needed to delay or potentially avoid, the need for valve surgery. Currently, there are no established disease modifying treatments in regard to the progression of aortic stenosis. The first results about influence of angiotensin-converting enzyme inhibitors and statins on aortic sclerosis and stenosis progression are promising. Statins are likely to reduce cardiovascular events rather than disease progression, but may be potentially a valuable preventive treatment in these patients. The prejudice against the use of angiotensin-converting enzyme inhibitors by patients with aortic stenosis is changing. The cautious use of angiotensin-converting enzyme inhibition by patients with concomitant hypertension, coronary artery disease, and heart failure seems appropriate. Definite evidence from large clinical trials is awaited.