Sanjay Divakaran

Incremental prognostic value of kidney function decline over coronary artery disease for cardiovascular event prediction after coronary computed tomography

It is unknown whether mild chronic kidney disease (CKD) is associated with adverse cardiovascular (CV) prognosis after accounting for coronary artery disease (CAD). Here we evaluated the interplay between CKD and CAD in predicting CV death or myocardial infarction (MI) and all-cause death. We included 1541 consecutive patients in the Partners registry (mean age 55 years, 43% female) over 18 years old with no known prior CAD who underwent coronary computed tomography angiography (CCTA). The results of CCTA were categorized as normal, nonobstructive (under half), or obstructive (half and over). Overall, 653 of the patients had no CAD, 583 had nonobstructive CAD, and 305 had obstructive CAD, while 1299 had eGFR over 60 ml/min per 1.73 m(2) and 242 had an eGFR under this value. The presence and severity of CAD was significantly associated with an increased rate of CV death or MI and all-cause death, even after adjustment for age, gender, symptoms, and risk factors. Similarly, reduced eGFR was significantly associated with CV death or MI and all-cause death after similar adjustment. The addition of reduced GFR to a model which included both clinical variables and CCTA findings resulted in significant improvement in the prediction of CV death or MI and all-cause death. Thus, among individuals referred for CCTA to evaluate CAD, renal dysfunction is associated with an increased rate of CV events, mainly driven by an increase in the rate of noncoronary CV events. In this group of patients, both eGFR and the presence and severity of CAD together improve the prediction of future CV events and death.

Use of cardiac CT and calcium scoring for detecting coronary plaque: implications on prognosis and patient management

Clinicians often use risk factor-based calculators to estimate an individuals risk of developing cardiovascular disease. Non-invasive cardiovascular imaging, particularly coronary artery calcium (CAC) scoring and coronary CT angiography (CTA), allows for direct visualization of coronary atherosclerosis. Among patients without prior coronary artery disease, studies examining CAC and coronary CTA have consistently shown that the presence, extent and severity of coronary atherosclerosis provide additional prognostic information for patients beyond risk factor-based scores alone. This review will highlight the basics of CAC scoring and coronary CTA and discuss their role in impacting patient prognosis and management.

Study of young patients with myocardial infarction: Design and rationale of the YOUNG-MI Registry

The YOUNG‐MI registry is a retrospective study examining a cohort of young adults age ≤ 50 years with a first‐time myocardial infarction. The study will use the robust electronic health records of 2 large academic medical centers, as well as detailed chart review of all patients, to generate high‐quality longitudinal data regarding the clinical characteristics, management, and outcomes of patients who experience a myocardial infarction at a young age. Our findings will provide important insights regarding prevention, risk stratification, treatment, and outcomes of cardiovascular disease in this understudied population, as well as identify disparities which, if addressed, can lead to further improvement in patient outcomes.

Comparison of the Use of Downstream Tests After Exercise Treadmill Testing by Cardiologists Versus Noncardiologists

Although exercise treadmill testing (ETT) is a useful initial test for patients with suspected cardiovascular (CV) disease, there is concern regarding the use of downstream imaging tests especially in the setting of equivocal or positive ETTs. Patients with no history of coronary artery disease who underwent ETT between 2009 and 2010 were prospectively included. Referring physicians were categorized as cardiologists and noncardiologists. Downstream tests included nuclear perfusion imaging, coronary computed tomography angiography, stress echocardiography, stress magnetic resonance, and invasive coronary angiography performed up to 6 months after the ETT. Patients were followed for CV death, myocardial infarction, and coronary revascularization for a median of 2.7 years. Among 3,656 patients, the ETT were negative in 2,876 (79%), positive in 132 (3.6%), and inconclusive in 643 (18%). Cardiologists ordered less downstream tests than noncardiologists (9.5% vs 12.2%, p=0.02), with less noninvasive tests (5.9% vs 10.4%, p<0.0001) and more invasive angiography (3.6% vs 1.8%, p<0.0001). After adjustment for confounding, patients evaluated by cardiologists were less likely to undergo additional testing after equivocal (odds ratio: 0.65, p=0.02) or positive ETT results (odds ratio: 0.39, p=0.02), whereas after negative ETT, the odds ratio was 1.7 (p=0.06). There was no difference in the rate of adverse CV events between patients referred by cardiologists versus noncardiologists. In conclusion, patients referred for ETT by cardiologists are less likely to undergo additional testing, particularly noninvasive tests, than those referred by noncardiologists. The lower rate of tests is driven by a lower rate of tests after positive or inconclusive ETT.

TYPE 2 MYOCARDIAL INFARCTION IN YOUNG PATIENTS PORTENDS A WORSE LONG-TERM SURVIVAL

Background: Recent data suggests that patients with Type 2 Myocardial Infarction (T2-MI) have a worse prognosis than previously appreciated. Yet, little is known about the implications of having a T2-MI at a young age. Methods: Using clinical & billing data, we identified all patients presenting

Role of Imaging in Evaluating Infiltrative Heart Disease

Opinion statementInfiltrative heart disease is caused by the deposition of abnormal substances in the heart and can lead to abnormalities in cardiac function and electrical conduction. Advances in non-invasive cardiovascular imaging have allowed for improved diagnosis of infiltrative heart disease, as well as ways to track disease progression or regression, thus enabling a mechanism to follow response to therapy. In this review, we provide an overview of the role of imaging in the diagnosis and management of cardiac sarcoidosis (CS) and cardiac amyloidosis (CA), as well as outline a proposed algorithm for using non-invasive cardiovascular imaging for evaluating these conditions.