Waleed Ahmed

Utility of the Neutrophil to Lymphocyte Ratio in Predicting Long-Term Outcomes in Acute Decompensated Heart Failure

Neutrophil-to-lymphocyte ratio (NLR) has been associated with poor outcomes in patients with acute coronary syndromes. However, its role for risk stratification in acute decompensated heart failure (ADHF) has not been well described. In this study, 1,212 consecutive patients admitted with ADHF who had total white blood cell and differential counts measured at admission were analyzed. The patients were divided into tertiles according to NLR. The association between NLR and white blood cell types with all-cause mortality was assessed using Cox regression analysis. During a median follow-up period of 26 months, a total of 284 patients (23.4%) had died, and a positive trend between death and NLR was observed; 32.8%, 23.2%, and 14.2% of deaths occurred in the higher, middle, and lower tertiles, respectively (p <0.001). After adjusting for confounding factors, multivariate analysis demonstrated that patients in the higher NLR tertile had the highest mortality (adjusted hazard ratio 2.23, 95% confidence interval (CI) 1.63 to 3.02, p <0.001), followed by those in the middle tertile (adjusted hazard ratio 1.62, 95% CI 1.16 to 2.23, p = 0.001). Furthermore, tertiles of NLR were superior in predicting long-term mortality compared with white blood cell, neutrophil, and relative lymphocyte counts. Patients in the higher NLR tertile (adjusted odds ratio 3.46, 95% CI 2.11 to 5.68, p <0.001) had a significantly higher 30-day readmission rate. In conclusion, higher NLR, an emerging marker of inflammation, is associated with an increased risk for long-term mortality in patients admitted with ADHF. NLR is a readily available inexpensive marker to aid in the risk stratification of patients with ADHF.

Single Resting hsTnT Level Predicts Abnormal Myocardial Stress Test in Acute Chest Pain Patients With Normal Initial Standard Troponin

OBJECTIVES The goal of this study was to determine the ability of a single, resting high-sensitivity troponin T (hsTnT) measurement to predict abnormal myocardial perfusion imaging (MPI) in patients presenting with acute chest pain to the emergency department (ED). BACKGROUND HsTnT assays precisely detect very low levels of troponin T, which may be a surrogate for the presence and extent of myocardial ischemia. METHODS We included all patients from the ROMICAT I (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial, an observational cohort study, who underwent both single-photon emission computed tomography (SPECT)-MPI stress testing and 64-slice computed tomography angiography (CTA) and in whom hsTnT measurements were available. We assessed the discriminatory value of hsTnT for abnormal SPECT-MPI and the association of reversible myocardial ischemia by SPECT-MPI and the extent of coronary atherosclerosis by CTA to hsTnT levels. RESULTS Of the 138 patients (mean age 54 ± 11 years, 46% male), 19 (13.7%) had abnormal SPECT-MPI. Median hsTnT levels were significantly different between patients with normal and abnormal SPECT-MPI (9.41 pg/ml [interquartile range (IQR): 5.73 to 19.20 pg/ml] vs. 4.89 pg/ml [IQR: 2.34 to 7.68 pg/ml], p = 0.001). Sensitivity of 80% and 90% to detect abnormal SPECT-MPI was reached at hsTnT levels as low as 5.73 and 4.26 pg/ml, respectively. Corresponding specificity was 62% and 46%, and negative predictive value was 96% and 96%, respectively. HsTnT levels had good discriminatory ability for prediction of abnormal SPECT-MPI (area under the curve: 0.739, 95% confidence interval: 0.609 to 0.868). Both reversible myocardial ischemia and the extent of coronary atherosclerosis (combined model r(2) = 0.19 with partial of r(2) = 0.12 and r(2) = 0.05, respectively) independently and incrementally predicted the measured hsTnT levels. CONCLUSIONS In patients with acute chest pain, myocardial perfusion abnormalities and coronary artery disease are predicted by resting hsTnT levels. Prospective evaluations are warranted to confirm whether resting hsTnT could serve as a powerful triage tool in chest pain patients in the ED before diagnostic testing and improve the effectiveness of patient management.

Comparison of Exercise Treadmill Testing With Cardiac CT Angiography Among Patients Presenting To The Emergency Room With Chest Pain: ROMICAT Study

Background —The aim of our study was to (a) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, (b) identify patient characteristics that may be used in selecting ETT versus CTA. Methods and Results —The Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a non-ischemic electrocardiogram. Univariate and multivariable analysis were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Out of the 220 patients who had ETT (mean age 51, 63% male), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male gender, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke treadmill score. Both a positive ETT and a low Duke treadmill score were significant univariate and multivariable predictors of stenosis >50% on CTA While the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 or women <50 years old or individuals who achieved at least 13 METS on ETT. Conclusions —Among low to intermediate risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. While patients with a high number of clinical risk factors are more likely to have obstructive CAD, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and, therefore, may benefit from initial ETT testing instead of CTA.Background— The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA. Methods and Results— The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis >50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 years old or women <50 years old or individuals who achieved at least 13 metabolic equivalents on ETT. Conclusions— Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.

Comparison of Exercise Treadmill Testing With Cardiac Computed Tomography Angiography Among Patients Presenting to the Emergency Room With Chest Pain The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) Study

Background —The aim of our study was to (a) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, (b) identify patient characteristics that may be used in selecting ETT versus CTA. Methods and Results —The Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a non-ischemic electrocardiogram. Univariate and multivariable analysis were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Out of the 220 patients who had ETT (mean age 51, 63% male), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male gender, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke treadmill score. Both a positive ETT and a low Duke treadmill score were significant univariate and multivariable predictors of stenosis >50% on CTA While the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 or women <50 years old or individuals who achieved at least 13 METS on ETT. Conclusions —Among low to intermediate risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. While patients with a high number of clinical risk factors are more likely to have obstructive CAD, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and, therefore, may benefit from initial ETT testing instead of CTA.Background— The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA. Methods and Results— The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis >50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 years old or women <50 years old or individuals who achieved at least 13 metabolic equivalents on ETT. Conclusions— Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.

Defining left ventricular noncompaction using cardiac computed tomography.

Purpose: Left ventricular noncompaction (LVNC) is a cardiomyopathy characterized by a distinctive 2-layered appearance of the myocardium because of increased trabeculation and deep intertrabecular recesses. Echocardiography serves as the initial noninvasive diagnostic test. Currently, magnetic resonance imaging (MRI) is increasingly being used to diagnose LVNC because of its improved temporal and spatial resolution. So far, no criteria have been proposed to define pathologic LVNC with the use of computed tomography (CT). Materials and Methods: We analyzed CT images using an American Heart Association 17-segment model in 8 patients previously diagnosed with LVNC by clinical diagnosis, echocardiography, and/or MRI, as well as in 11 patients with nonischemic dilated cardiomyopathy, 11 patients with hypertrophic cardiomyopathy, 10 patients with severe aortic stenosis, 9 patients with severe aortic regurgitation, 10 patients with left ventricular hypertrophy due to essential hypertension, and, additionally, in a control group of 20 patients who had normal CT scans without a history of cardiovascular disease. The distribution of LVNC was assessed by qualitative analysis of 17 myocardial segments for the presence or absence of any degree of noncompaction. Each segment was analyzed in each of the 3 end-diastolic long-axis views for the presence or absence of noncompaction, and the most prominent trabeculation was chosen for measurement. The left ventricular apex was excluded. Thickness of noncompacted and compacted myocardium was measured perpendicular to the compacted myocardium. The ratio of noncompacted to compacted (NC:C) myocardium was calculated for each segment. Receiver operating characteristics were used to generate cutoff values with sensitivity and specificity to distinguish the LVNC group from other groups. Results: An end-diastolic NC:C ratio >2.3 distinguished pathologic LVNC with 88% sensitivity and 97% specificity; positive and negative predictive values were 78% and 99%, respectively. Conclusions: CT using the standard MRI NC:C ratio cutoff >2.3 accurately characterizes pathologic LVNC.

Early Resting Myocardial Computed Tomography Perfusion for the Detection of Acute Coronary Syndrome in Patients With Coronary Artery Disease

Background—Acute rest single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) has high predictive value for acute coronary syndrome (ACS) in emergency department patients. Prior studies have shown excellent agreement between rest/stress computed tomography perfusion (CTP) and SPECT-MPI, but the value of resting CTP (rCTP) in acute chest pain triage remains unclear. We sought to determine the diagnostic accuracy of early rCTP, incremental value beyond obstructive coronary artery disease (CAD; ≥50% stenosis), and compared early rCTP to late stress SPECT-MPI in patients with CAD presenting with suspicion of ACS to the emergency department. Methods and Results—In this prespecified subanalysis of 183 patients (58.1±10.2 years; 33% women), we included patients with any CAD by coronary computed tomography angiography (CCTA) from Rule Out Myocardial Infarction Using Computer-Assisted Tomography I. rCTP was assessed semiquantitatively, blinded to CAD interpretation. Overall, 31 had ACS and 48 had abnormal rCTP. Sensitivity and specificity of rCTP for ACS were 48% (95% confidence interval [CI], 30%–67%) and 78% (95% CI, 71%–85%), respectively. rCTP predicted ACS (adjusted odds ratio, 3.40 [95% CI, 1.37–8.42]; P=0.008) independently of obstructive CAD, and sensitivity for ACS increased from 77% (95% CI, 59%–90%) for obstructive CAD to 90% (95% CI, 74%–98%) with addition of rCTP (P=0.05). In a subgroup undergoing late rest/stress SPECT-MPI (n=81), CCTA/rCTP had noninferior discriminatory value to CCTA/SPECT-MPI (area under the curve, 0.88 versus 0.90; P=0.64) using a noninferiority margin of 10%. Conclusions—Early rCTP provides incremental value beyond obstructive CAD to detect ACS. CCTA/rCTP is noninferior to CCTA/SPECT-MPI to discriminate ACS and presents an attractive alternative to triage patients presenting with acute chest pain. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00990262.

Prognostic value of different cardiac MRI parameters for the diagnosis of myocarditis

Results 209 cases were reviewed; mean age 47 and 58% men. 74 (35%) patients were diagnosed with myocarditis based on CMR. The number of patients with 0, 1, 2 and 3 criteria positive was 70 (33%), 65 (31%), 49 (23%) and 25 (12%) respectively. Age, gender, diabetes, hypertension, smoking, CAD, prior CHF and CRI were similar among all groups. There was a trend for higher prevalence of NYHA class III or IV in myocarditis patients (17% vs 7.8 %; P=0.05). Baseline LVEF was 48.44±18 by TTE and 46±21 by CMR with no significant differences between groups. Mean increase in LVEF at 6 months by TTE for patients with 0, 1, 2 and 3 criteria positive was 5±10, 13±11, 11±10 and 6±12 (P=0.147). Mean change in LVEF for three myocarditis groups based on abnormal T1 and T2, T1 and DE or T2 and DE was 10±9, 10±7 and 7±9 (P=0.39). MACE was achieved in 20 (37%) patients with myocarditis and 21 (23%) patients without the diagnosis (P=0.078). The rate of MACE in patients with 0, 1, 2 and 3 positive criteria was 11 (22%), 10 (25%), 13 (37%) and 7 (37%) (P=0.127 and 0.21 for 0 vs 2 and 0 vs 3 criteria). The three groups based on positive T1 and T2, T1 and DE or T2 and DE had MACE rates of 3 (23%), 5 (38%) and 5 (38%) with no significant differences on pairwise comparisons.

The utility of delayed-enhancement and t2-weighted cardiovascular mri for predicting clinical outcomes in patients at high risk for cardiac sarcoidosis.

The utility of delayed-enhancement (DE) has been extensively studied in patients with sarcoidosis who are asymptomatic or at low risk for cardiac involvement. However, there is lack of data regarding the utility of DE in patients with sarcoidosis who present with high grade cardiovascular symptoms. Also, the utility of T2-weighted imaging has not been evaluated in these patients.

Prevalence of fat by cardiac magnetic resonance imaging stratified by age in 940 patients referred for evaluation of arrhythmogenic (rv) dysplasia

37.8 ± 16.3, p < 0.0001, respectively). Patients in T3 tended to have a higher proportion of severe fat in the RV compared to patients in T2 (10.8% vs. 5.9%, p =0.03) and T1 (10.8% vs. 0.7%, p < 0.0001). Also, patients in T3 tended to have higher proportion of moderate fat in the RV compared to patients in T2 (13.2% vs. 8.9%, p =0.09) and T1 (13.2% vs. 3.3%, p<0.001). Finally, T3 patients tended to have the lowest proportion of RV without fat compared to patients in T2 and T1 (42.3% vs. 58.8 % vs. 75.1%, respectively; p < 0.0001). Full fat and age distribution by tertiles are depicted in Fig 1.