On aika siirtyä geeneistä eteenpäin

Tautien määritykseen ja ennakointiin tarvitaan uusia näköaloja. Potilaille pitää osata kertoa, että geenien osuus terveydessä on vähäinen verrattuna elämäntapoihin. </p

Sydämen PET-tutkimukset

Sydämen positroniemissiotomografia (PET) -kuvien erinomainen laatu ja kvantitatatiiviset analyysit tuottavat tarkkaa ja luotettavaa tietoa sydänsairauksiin, kuten sepelvaltimotauteihin, sydänsarkoidoosiin ja sydämen infektioihin liittyvistä häiriöistä. Sydänlihasperfuusion eli sydänlihaksen verenkierron jakauman määritys anatomisen kuvantamisen ohella kertoo sepelvaltimoahtautumien hemodynaamisen merkityksen, mikä ohjaa potilaiden hoitoratkaisuja. Absoluuttisen sydänlihasperfuusion mittauksella diagnostiikan luotettavuus paranee etenkin potilailla, joilla perfuusio poikkeaa laajasti. Sydämen aineenvaihdunnan PET-tutkimukset mahdollistavat tulehdusaktiviteetin havaitsemisen sydämen rakenteissa, mitä käytetään hyväksi etenkin sydänsarkoidoosiin ja infektioiden toteamiseen. Viabiliteettia eli sydänlihaskudoksen elinkykyisyyttä tutkittaessa yhdistetään PET-tutkimusten tuottamaa tietoa sydänlihaksen perfuusiosta ja glukoosiaineenvaihdunnasta. Perfuusiopuutosalueilla normaalina säilynyt glukoosiaineenvaihdunta kuvaa elinkelpoista sydänlihasta, jolla on kyky funktionaaliseen palautumiseen revaskularisaatiotoimenpiteiden jälkeen

ESC 2019 guidelines for the diagnosis and management of chronic coronary syndromes Recommendations for cardiovascular imaging

The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of "clinical likelihood of CAD" was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms

On aika siirtyä geeneistä eteenpäin

Tautien määritykseen ja ennakointiin tarvitaan uusia näköaloja. Potilaille pitää osata kertoa, että geenien osuus terveydessä on vähäinen verrattuna elämäntapoihin

Increased B-Type Natriuretic Peptide Concentration Is Associated with Reduced Coronary Vasoreactivity in Patients with Dilated Cardiomyopathy but Not in Healthy Young Subjects

Background/Aims. Natriuretic peptides are associated with the cardiovascular disease risk under a range of different circumstances. However, less is known about whether this association is found also in young healthy subjects. Methods. 9 patients with dilated cardiomyopathy and 26 healthy young subjects were studied. The myocardial blood flow measurements were performed basally and during adenosine infusion using PET. Results. S-proBNP concentrations were significantly higher (2153 ± 1964 versus 28 ± 17 ng/L, P = .000002) and adenosine-stimulated flow lower (1.6 ± 0.8 versus 3.6 ± 1.1 mL·g−1·min−1, P = .00001) in patients with dilated cardiomyopathy when compared to healthy subjects. S-proBNP concentration was inversely associated with adenosine stimulated flow in patients with dilated cardiomyopathy (r = −0.75, P = .019) but not in healthy subjects (r = −0.06, P = .84). Conclusions. Natriuretic peptides are inversely associated with coronary vasoreactivity in patients with dilated cardiomyopathy but not in healthy young subjects. Since reduced coronary vasoreactivity seems to be one of the earliest abnormalities in the development of coronary artery disease, this might indicate that natriuretic peptides are not predictor of cardiovascular disease risk in healthy young subjects

Cardiac perfusion by positron emission tomography

Myocardial perfusion imaging (MPI) with positron emission tomography (PET) is an established tool for evaluation of obstructive coronary artery disease (CAD). The contemporary 3-dimensional scanner technology and the state-of-the-art MPI radionuclide tracers and pharmacological stress agents, as well as the cutting-edge image reconstruction techniques and data analysis software, have all enabled accurate, reliable and reproducible quantification of absolute myocardial blood flow (MBF), and henceforth calculation of myocardial flow reserve (MFR) in several clinical scenarios. In patients with suspected coronary artery disease, both absolute stress MBF and MFR can identify myocardial territories subtended by epicardial coronary arteries with haemodynamically significant stenosis, as defined by invasive coronary fractional flow reserve measurement. In particular, absolute stress MBF and MFR offered incremental prognostic information for predicting adverse cardiac outcome, and hence for better patient risk stratification, over those provided by traditional clinical risk predictors. This article reviews the available evidence to support the translation of the current techniques and technologies into a useful decision-making tool in real-world clinical practice

Performance of the American Heart Association/American College of Cardiology Guideline-Recommended Pretest Probability Model for the Diagnosis of Obstructive Coronary Artery Disease

BACKGROUND: Substantial differences exist between different guideline‐recommended pretest probability (PTP) models for the detection of obstructive coronary artery disease (CAD). This study was performed to study the performance of the 2021 American Heart Association/American College of Cardiology (AHA/ACC) guideline‐recommended PTP (AHA/ACC‐PTP) model in assessing the likelihood of obstructive CAD compared with previously proposed models. METHODS AND RESULTS: Symptomatic patients (N=50 561) referred for coronary computed tomography angiography were included. The reference standard was invasive coronary angiography with optional fractional flow reserve measurements. The AHA/ACC‐PTP values based on sex and age were calculated and compared with the 2019 European Society of Cardiology guideline PTP values based on sex, age, and symptoms as well as the risk factor–weighted clinical likelihood values based on sex, age, symptoms, and risk factors. The AHA/ACC‐PTP maximum values overestimated by a factor of 2.6 the actual prevalence of CAD. Compared with the AHA/ACC‐PTP model (area under the receiver‐operating curve, 71.5 [95% CI, 70.7–72.2]), inclusion of typicality of symptoms in the European Society of Cardiology guideline PTP improved discrimination of CAD (area under the receiver‐operating curve, 75.5 [95% CI, 74.7–76.3]). Inclusion of both symptoms and risk factors in the risk factor–weighted clinical likelihood model further improved discrimination (area under the receiver‐operating curve, 77.7 [95% CI, 77.0–78.5]). The proportion of patients classified as very low PTP was lower using the AHA/ACC‐PTP (5%) compared with the European Society of Cardiology guideline PTP (19%) and the risk factor–weighted clinical likelihood (49%) models. CONCLUSIONS: The new AHA/ACC‐PTP model overestimates the prevalence of obstructive CAD substantially if type of symptoms and risk factors are not taken into account. Inclusion of both symptoms and risk factors improves model performance and identifies more patients with very low likelihood of CAD in whom further testing can be deferred