Faraz Kureshi

Comparison of Clinical Interpretation with Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice: The Assessing Angiography (A2) Project

Background— Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently undertaken. Methods and Results— We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention at 7 US hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen weighted &kgr; statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (quartiles 1 and 3, 80.0% and 90.0%), with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was 8.2±8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted &kgr; of 0.27 (95% confidence interval, 0.18–0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA, although none were <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50% to <70%), with variation existing across sites. Conclusions— Physicians tended to assess coronary lesions treated with percutaneous coronary intervention as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, whereas approximately one quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.

Variation in patients’ perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

Objectives To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers. Design Cross sectional study. Setting 10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011. Participants 991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention. Main outcome measures Patients’ perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients’ understanding across centers and operators after adjusting for patient characteristics, using median odds ratios. Results The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients’ perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site. Conclusion Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

The prevalence and management of angina among patients with chronic coronary artery disease across US outpatient cardiology practices: insights from the Angina Prevalence and Provider Evaluation of Angina Relief (APPEAR) study

Although eliminating angina is a primary goal in treating patients with chronic coronary artery disease (CAD), few contemporary data quantify prevalence and severity of angina across US cardiology practices. The authors hypothesized that angina among outpatients with CAD managed by US cardiologists is low and its prevalence varies by site. Among 25 US outpatient cardiology clinics enrolled in the American College of Cardiology Practice Innovation and Clinical Excellence (PINNACLE) registry, we prospectively recruited a consecutive sample of patients with chronic CAD over a 1‐ to 2‐week period at each site between April 2013 and July 2015, irrespective of the reason for their appointment. Eligible patients had documented history of CAD (prior acute coronary syndrome, prior coronary revascularization procedure, or diagnosis of stable angina) and ≥1 prior office visit at the practice site. Angina was assessed directly from patients using the Seattle Angina Questionnaire Angina Frequency score. Among 1257 patients from 25 sites, 7.6% (n = 96) reported daily/weekly, 25.1% (n = 315) monthly, and 67.3% (n = 846) no angina. The proportion of patients with daily/weekly angina at each site ranged from 2.0% to 24.0%, but just over half (56.3%) were on ≥2 antianginal medications, with wide variability across sites (0%–100%). One‐third of outpatients with chronic CAD managed by cardiologists report having angina in the prior month, and 7.6% have frequent symptoms. Among those with frequent angina, just over half were on ≥2 antianginal medications, with wide variability across sites. These findings suggest an opportunity to improve symptom control.

Comparison of Clinical Interpretation With Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice

Background— Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently undertaken. Methods and Results— We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention at 7 US hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen weighted &kgr; statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (quartiles 1 and 3, 80.0% and 90.0%), with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was 8.2±8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted &kgr; of 0.27 (95% confidence interval, 0.18–0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA, although none were <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50% to <70%), with variation existing across sites. Conclusions— Physicians tended to assess coronary lesions treated with percutaneous coronary intervention as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, whereas approximately one quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.

Regadenoson-induced complete heart block and asystole: A real possibility nuclear laboratories should be aware of

Regadenoson, a selective A2A adenosine receptor agonist, was approved by the FDA in 2008 for use as a pharmacologic stress agent during radionuclide myocardial perfusion imaging. This was based primarily on the results of the ADVANCE trial that showed non-inferiority to adenosine in the evaluation of ischemic heart disease. Although no cases of high-grade AV block or sinus arrest were reported in the ADVANCE study, these arrhythmias have been observed subsequent to regadenoson’s widespread clinical use. While only a small number of cases have been reported in the literature, the FDA has been notified of 47 instances of complete heart block and 25 cases of sinus arrest as of June 30, 2016. Accordingly, it is certainly plausible that regadenoson may have significant cardiac clinical effects beyond the A2A receptor. We present a report of complete AV nodal block and asystole after regadenoson administration in a stable patient no prior suggestion high conduction system disease, and normal kidney function.

ISCHEMIA, to revascularize or not to revascularize.

Management of patients with coronary artery disease is focused on preventing cardiovascular events, improving survival, and control of anginal symptoms, and the cornerstone of treatment is optimal medical therapy with or without coronary revascularization. When these options of therapy have been compared among patients with stable ischemic heart disease, the benefits of coronary revascularization in addition to optimal medical therapy is not as clear as among patients with acute coronary syndrome. This is based on the results of several large randomized clinical trials that have failed to show a consistent superiority of one treatment strategy compared to the other. However, some results from observational studies have suggested that coronary revascularization may be superior to optimal medical therapy among patients with significant ischemia. The above-mentioned hypothesis served as the nidus behind the ongoing National Heart, Lung, and Blood Institute-funded ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches; NCT01471522). In this trial, patients with stable ischemic heart disease and at least moderate ischemia will be randomized to optimal medical therapy with or without coronary revascularization to definitively answer the ongoing dilemma whether an invasive strategy with revascularization improves long-term outcomes in a randomized controlled trial. Although ischemia can be detected and quantified through multiple modalities, the richest data confirming the role of myocardial ischemia as a strong prognostic factor come from nuclear imaging. In this issue of the journal, Nudi et al reports a single-center, retrospective observational study evaluating the impact of coronary revascularization as compared to medical therapy on ischemia in patients undergoing serial stressand rest-gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) studies. In order to better evaluate a cohort of patients with stable ischemic heart disease, patients were excluded if they had unstable angina in the prior 6 months, prior myocardial infarction, reduced left ventricular ejection fraction (\45%), or a left ventricular end diastolic volume index[ 130 ml/m. Ischemia was semi-quantified by 2 experienced unblinded readers based on previously published (but not widely adopted) seven-region segmentation approach for left ventricular myocardium corresponding to a maximal ischemia score (MIS) group (no, minimal, mild, moderate, or severe ischemia). The authors identified a total of 3631 patients who underwent serial SPECT MPI between the years of 2004-2014 with 27% (n = 967) undergoing coronary revascularization and 73% (n = 2664) receiving only medical therapy at baseline. Multivariable adjustment and propensity score methodologies were used to minimize the effect of confounders. Unadjusted analyses revealed that revascularization was more effective than medical therapy in reducing myocardial ischemia in those patients with baseline moderate or greater MIS scores. All adjusted and propensity-matched analyses suggested a lower odds of a unit increase in MIS scores of patients who underwent revascularization as compared to medical therapy alone. Given the observational nature of this study, several limitations should be noted. First, the study is subject to selection biases based on inclusion criteria and treatment assignment. Although the authors attempted to control for confounding using adjustment methods and Reprint requests: Mouin S. Abdallah, MD, MSc, Saint Luke’s Mid America Heart Institute, University of Missouri Kansas City, Kansas City, MO; mouinabdallah2010@gmail.com J Nucl Cardiol 2017;24:1699–701. 1071-3581/

PREDICTING THE LIKELIHOOD FOR CORONARY ARTERY BYPASS GRAFTING IN NON ST ELEVATION MYOCARDIAL INFARCTION PATIENTS

34.00 Copyright 2016 American Society of Nuclear Cardiology.

The “absent” left atrial appendage…

Current ACC/AHA guidelines recommend dual antiplatelet therapy (DAPT) on presentation in patients with non ST elevation myocardial infarction (NSTEMI). This practice, however, can complicate coronary artery bypass (CABG) procedures, required in 8% to 25% of NSTEMI patients, and lead to delays in

OBESITY PARADOX AND ANGINA FREQUENCY IN PATIENTS PRESENTING WITH ACUTE MYOCARDIAL INFARCTION

Introduction Isolated congenital absence of the left atrial appendage (LAA) is a rare condition. The diagnosis results from a review of the past medical and surgical history in addition to the use of multimodality imaging, as several other conditions (thrombotic occlusion, surgical or percutaneous exclusion, variations in morphology and relative position of anatomic structures) may present with a similar finding.

PROVIDER VARIABILITY AND CHARACTERISTICS ASSOCIATED WITH BIVALIRUDIN USE FOR BLEEDING AVOIDANCE IN PERCUTANEOUS CORONARY INTERVENTION AFTER IMPLEMENTATION OF A DECISION SUPPORT TOOL

An “obesity paradox” of better long-term survival is reported in obese patients after acute myocardial infarction (AMI). The association of obesity and angina burden after AMI is not known. We prospectively enrolled 6,838 AMI patients from 31 US sites and categorized them by BMI into normal